Provider Demographics
NPI:1336120260
Name:GRIDLEY, GARY DOUGLAS (MD)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:DOUGLAS
Last Name:GRIDLEY
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 1:1200 N BEAVER ST
Mailing Address - Street 2:PAYER CREDENTIALING
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86001-3118
Mailing Address - Country:US
Mailing Address - Phone:928-213-6235
Mailing Address - Fax:
Practice Address - Street 1:269 S CANDY LN
Practice Address - Street 2:
Practice Address - City:COTTONWOOD
Practice Address - State:AZ
Practice Address - Zip Code:86326-4158
Practice Address - Country:US
Practice Address - Phone:928-639-6150
Practice Address - Fax:928-639-6561
Is Sole Proprietor?:No
Enumeration Date:2005-11-08
Last Update Date:2022-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00030603207L00000X
AZ30200207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8930278OtherCRIME VICTIMS PGM
WA5647GROtherREGENCE BLUE SHIELD
WA0181547OtherDEPT OF LABOR & INDUSTRIE
WA8312498Medicaid
WA5647GROtherREGENCE BLUE SHIELD
WA8801917Medicare ID - Type Unspecified