Provider Demographics
NPI:1316214281
Name:GRIESSER, CARL RUSSELL (MD)
Entity Type:Individual
Prefix:
First Name:CARL
Middle Name:RUSSELL
Last Name:GRIESSER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2825 E BARNETT RD
Mailing Address - Street 2:MSS
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-8332
Mailing Address - Country:US
Mailing Address - Phone:541-789-4281
Mailing Address - Fax:541-789-4806
Practice Address - Street 1:2828 E BARNETT RD
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-8342
Practice Address - Country:US
Practice Address - Phone:541-789-8000
Practice Address - Fax:541-789-8225
Is Sole Proprietor?:No
Enumeration Date:2011-11-21
Last Update Date:2023-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD155331207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR067665OtherOMAP
OR227698Medicaid
OR500642273Medicaid