Provider Demographics
NPI:1033188677
Name:GRISSOM, DAVID B (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:B
Last Name:GRISSOM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 99335
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76199-0335
Mailing Address - Country:US
Mailing Address - Phone:817-920-7340
Mailing Address - Fax:
Practice Address - Street 1:855 MONTGOMERY
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76107-2553
Practice Address - Country:US
Practice Address - Phone:817-920-7340
Practice Address - Fax:817-534-0729
Is Sole Proprietor?:No
Enumeration Date:2006-03-16
Last Update Date:2011-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK7547207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX111903406Medicaid
TX8J9055OtherBCBS
TXP00312850OtherRAILROAD MEDICARE
TXF70657Medicare UPIN
TX8J9055OtherBCBS