Provider Demographics
NPI:1336102359
Name:GRISOLIA, JAMES SANTIAGO (MDINC)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:SANTIAGO
Last Name:GRISOLIA
Suffix:
Gender:M
Credentials:MDINC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4033 3RD AVE
Mailing Address - Street 2:SUITE 410
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92103-2117
Mailing Address - Country:US
Mailing Address - Phone:619-297-1155
Mailing Address - Fax:
Practice Address - Street 1:4033 3RD AVE
Practice Address - Street 2:SUITE 410
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-2117
Practice Address - Country:US
Practice Address - Phone:619-297-1155
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-10
Last Update Date:2015-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG428842084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G428840Medicaid
CAA49152Medicare UPIN
G42884Medicare ID - Type Unspecified