Provider Demographics
NPI:1306802426
Name:GRISWOLD, MARTHA A (MD)
Entity type:Individual
Prefix:DR
First Name:MARTHA
Middle Name:A
Last Name:GRISWOLD
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 1:430 CLAREMONT CT
Mailing Address - Street 2:SUITE 212
Mailing Address - City:COLONIAL HEIGHTS
Mailing Address - State:VA
Mailing Address - Zip Code:23834-1770
Mailing Address - Country:US
Mailing Address - Phone:804-520-0892
Mailing Address - Fax:804-520-0896
Practice Address - Street 1:173 WATERFRONT DR
Practice Address - Street 2:
Practice Address - City:COLONIAL HEIGHTS
Practice Address - State:VA
Practice Address - Zip Code:23834-2181
Practice Address - Country:US
Practice Address - Phone:804-520-5165
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101033077207RA0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RA0000XAllopathic & Osteopathic PhysiciansInternal MedicineAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA6097812Medicaid