Provider Demographics
NPI:1376075366
Name:GRISSOM, NICHOLAS BRADLEY (MD)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:BRADLEY
Last Name:GRISSOM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:NICHOLAS
Other - Middle Name:B
Other - Last Name:GRISSOM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:2170 MIDLAND RD
Mailing Address - Street 2:
Mailing Address - City:SOUTHERN PINES
Mailing Address - State:NC
Mailing Address - Zip Code:28387-2927
Mailing Address - Country:US
Mailing Address - Phone:910-295-2100
Mailing Address - Fax:910-295-3625
Practice Address - Street 1:3312 BATTLEGROUND AVE
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27410-2548
Practice Address - Country:US
Practice Address - Phone:336-282-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-30
Last Update Date:2023-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD204084207W00000X
NC202202395207WX0009X, 207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No207WX0009XAllopathic & Osteopathic PhysiciansOphthalmologyGlaucoma Specialist