Provider Demographics
NPI:1164400644
Name:GRISSOM, LARRY A (MD)
Entity Type:Individual
Prefix:DR
First Name:LARRY
Middle Name:A
Last Name:GRISSOM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:800 PEAKWOOD DR
Mailing Address - Street 2:SUITE 5E
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77090-2900
Mailing Address - Country:US
Mailing Address - Phone:281-440-5158
Mailing Address - Fax:281-440-8549
Practice Address - Street 1:800 PEAKWOOD DR
Practice Address - Street 2:SUITE 5E
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77090-2900
Practice Address - Country:US
Practice Address - Phone:281-440-5158
Practice Address - Fax:281-440-8549
Is Sole Proprietor?:No
Enumeration Date:2006-01-05
Last Update Date:2008-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF16052085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1253874-03Medicaid
TX1253874-03Medicaid
TXE12272Medicare UPIN