Provider Demographics
NPI:1407150113
Name:MEZA, GRISELDA MANI (MD)
Entity Type:Individual
Prefix:
First Name:GRISELDA
Middle Name:MANI
Last Name:MEZA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2200 OPITZ BLVD STE 355
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22191-3340
Mailing Address - Country:US
Mailing Address - Phone:703-580-6400
Mailing Address - Fax:703-580-4550
Practice Address - Street 1:14009 MINNIEVILLE RD
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22193-2310
Practice Address - Country:US
Practice Address - Phone:703-580-6400
Practice Address - Fax:703-580-6402
Is Sole Proprietor?:No
Enumeration Date:2011-01-10
Last Update Date:2019-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN5869208000000X
VA0101246974208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1407150113Medicaid