Provider Demographics
NPI:1326508805
Name:GRISDELA, PHILLIP THOMAS JR
Entity Type:Individual
Prefix:
First Name:PHILLIP
Middle Name:THOMAS
Last Name:GRISDELA
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 1:23 STETSON ST UNIT 1
Mailing Address - Street 2:
Mailing Address - City:BROOKLINE
Mailing Address - State:MA
Mailing Address - Zip Code:02446-7106
Mailing Address - Country:US
Mailing Address - Phone:703-673-6704
Mailing Address - Fax:
Practice Address - Street 1:1975 ZONAL AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90089-5601
Practice Address - Country:US
Practice Address - Phone:323-409-7347
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-21
Last Update Date:2024-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CAA194489207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program