Provider Demographics
NPI:1144391897
Name:GRISSOM, NIMA A (MD)
Entity Type:Individual
Prefix:
First Name:NIMA
Middle Name:A
Last Name:GRISSOM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3801 SACRAMENTO ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94118-1625
Mailing Address - Country:US
Mailing Address - Phone:415-600-1817
Mailing Address - Fax:415-600-1974
Practice Address - Street 1:3700 SACRAMENTO ST
Practice Address - Street 2:#100
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94118-1706
Practice Address - Country:US
Practice Address - Phone:415-292-8999
Practice Address - Fax:415-292-8990
Is Sole Proprietor?:No
Enumeration Date:2006-11-13
Last Update Date:2012-11-27
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAC38970208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
00C389700Medicare ID - Type Unspecified
A89069Medicare UPIN