Provider Demographics
NPI:1083714380
Name:GRILLOT, STEPHEN G (DO)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:G
Last Name:GRILLOT
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 1:2021 N AMIDON AVE STE 13
Mailing Address - Street 2:P.O. BOX 1179
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67203-2100
Mailing Address - Country:US
Mailing Address - Phone:316-832-0833
Mailing Address - Fax:316-219-2990
Practice Address - Street 1:132 W A AVE
Practice Address - Street 2:
Practice Address - City:KINGMAN
Practice Address - State:KS
Practice Address - Zip Code:67068-1305
Practice Address - Country:US
Practice Address - Phone:620-532-5800
Practice Address - Fax:620-532-3361
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-25
Last Update Date:2012-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS05-25303207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100237500FMedicaid
KS100237500OMedicaid
KSP00829200OtherRAILROAD THRU ST CATS
KSP00829200OtherRAILROAD THRU ST CATS
KS100237500OMedicaid
KSKA1209008Medicare PIN