Provider Demographics
NPI:1114366028
Name:GRIGSBY, CHARLES KEVIN (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:KEVIN
Last Name:GRIGSBY
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 936
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23501-0936
Mailing Address - Country:US
Mailing Address - Phone:757-446-8960
Mailing Address - Fax:757-446-5197
Practice Address - Street 1:825 FAIRFAX AVE STE 610
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23507-1912
Practice Address - Country:US
Practice Address - Phone:757-446-8960
Practice Address - Fax:757-446-5197
Is Sole Proprietor?:No
Enumeration Date:2013-06-25
Last Update Date:2023-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01012651202086S0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0102XAllopathic & Osteopathic PhysiciansSurgerySurgical Critical Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ075195Medicaid