Provider Demographics
NPI:1063449049
Name:GRILLS, JEFFREY DALE (MD)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:DALE
Last Name:GRILLS
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 1:1 CHILDRENS WAY # 844
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72202-3500
Mailing Address - Country:US
Mailing Address - Phone:501-364-2090
Mailing Address - Fax:501-364-3929
Practice Address - Street 1:2601 GENE GEORGE BLVD
Practice Address - Street 2:
Practice Address - City:SPRINGDALE
Practice Address - State:AR
Practice Address - Zip Code:72762
Practice Address - Country:US
Practice Address - Phone:479-725-6977
Practice Address - Fax:479-725-6577
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2018-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO112085208000000X
ARE10930208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100250370BMedicaid
MO107500OtherANTHEM
MO208684605Medicaid
KS100289710AMedicaid
AR224757001Medicaid