Provider Demographics
NPI:1285658815
Name:GRIVAS, ANDREW SCOTT JR
Entity Type:Individual
Prefix:DR
First Name:ANDREW
Middle Name:SCOTT
Last Name:GRIVAS
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1406 MISSOURI BLVD STE I
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON CITY
Mailing Address - State:MO
Mailing Address - Zip Code:65109-1737
Mailing Address - Country:US
Mailing Address - Phone:855-976-1888
Mailing Address - Fax:816-817-0655
Practice Address - Street 1:1406 MISSOURI BLVD STE I
Practice Address - Street 2:
Practice Address - City:JEFFERSON CITY
Practice Address - State:MO
Practice Address - Zip Code:65109-1737
Practice Address - Country:US
Practice Address - Phone:855-976-1888
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2024-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA016921207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAE01158Medicare UPIN