Provider Demographics
NPI:1043276934
Name:GRISIER, DOUGLAS B (DO)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:B
Last Name:GRISIER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 LECOM PL
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16505-2571
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:814-868-2522
Practice Address - Street 1:537 W 18TH ST
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16502-1722
Practice Address - Country:US
Practice Address - Phone:814-456-1009
Practice Address - Fax:814-454-6051
Is Sole Proprietor?:No
Enumeration Date:2006-04-21
Last Update Date:2023-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS006272L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0011212160002Medicaid
PA418349Medicare PIN
PA1121216Medicaid