Provider Demographics
NPI:1326085671
Name:GRIGOROPOULOS, JERRY (MD)
Entity Type:Individual
Prefix:DR
First Name:JERRY
Middle Name:
Last Name:GRIGOROPOULOS
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 1:101 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95354-0556
Mailing Address - Country:US
Mailing Address - Phone:209-571-6622
Mailing Address - Fax:209-527-2069
Practice Address - Street 1:1524 MCHENRY AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-4500
Practice Address - Country:US
Practice Address - Phone:209-571-6622
Practice Address - Fax:209-527-2069
Is Sole Proprietor?:No
Enumeration Date:2006-06-02
Last Update Date:2008-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA736142085B0100X, 2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085B0100XAllopathic & Osteopathic PhysiciansRadiologyBody Imaging
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A736140Medicaid
CA00A7361413Medicare PIN
CA00A736149Medicare PIN
CA00A736147Medicare PIN
CA00A736148Medicare PIN
CAH85702Medicare UPIN
CA00A7361411Medicare PIN
CA00A7361416Medicare PIN
CA00A736142Medicare PIN
CA00A736145Medicare PIN
CAP00051698Medicare PIN
CA00A736146Medicare PIN
CA00A7361410Medicare PIN
CA00A736141Medicare PIN
CA00A7361412Medicare PIN
CA00A7361415Medicare PIN
CA00A736143Medicare PIN
CA00A736144Medicare PIN