Provider Demographics
NPI:1043385131
Name:GRISSAM, TONYA (MD)
Entity Type:Individual
Prefix:
First Name:TONYA
Middle Name:
Last Name:GRISSAM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:TONYA
Other - Middle Name:MONIQUE
Other - Last Name:GRISSAM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:6451 N FEDERAL HWY STE 800
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33308-1409
Mailing Address - Country:US
Mailing Address - Phone:800-586-5022
Mailing Address - Fax:954-229-9801
Practice Address - Street 1:6451 N FEDERAL HWY STE 800
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33308-1409
Practice Address - Country:US
Practice Address - Phone:800-586-5022
Practice Address - Fax:954-229-9801
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-22
Last Update Date:2022-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301106345208000000X
GA051567208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000960913DMedicaid
GA000960913IMedicaid
GA000960913HMedicaid