Provider Demographics
NPI:1275500720
Name:GRIMES, MICHAEL (DPM)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:GRIMES
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2150 APPIAN WAY STE 206
Mailing Address - Street 2:
Mailing Address - City:PINOLE
Mailing Address - State:CA
Mailing Address - Zip Code:94564-2520
Mailing Address - Country:US
Mailing Address - Phone:510-724-1530
Mailing Address - Fax:
Practice Address - Street 1:2150 APPIAN WAY STE 206
Practice Address - Street 2:
Practice Address - City:PINOLE
Practice Address - State:CA
Practice Address - Zip Code:94564-2520
Practice Address - Country:US
Practice Address - Phone:510-724-1530
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-03
Last Update Date:2020-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1464213ES0103X
CAE4413213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAU76334Medicare UPIN
CA4730330001Medicare NSC