Provider Demographics
NPI:1417983792
Name:GRIGSBY, KENNETH (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:
Last Name:GRIGSBY
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:PO BOX 15645
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89114-5645
Mailing Address - Country:US
Mailing Address - Phone:702-877-8661
Mailing Address - Fax:702-877-5140
Practice Address - Street 1:2450 W CHARLESTON BLVD
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89102-2179
Practice Address - Country:US
Practice Address - Phone:702-877-8660
Practice Address - Fax:702-877-5140
Is Sole Proprietor?:No
Enumeration Date:2006-06-25
Last Update Date:2017-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV11862207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1417983792OtherMEDI-CAL
NV1417983792Medicaid
UT1770556037Medicaid
NV100510148Medicaid
WA8480675Medicaid
WA1417983792Medicaid
AR168644001Medicaid
P00618862OtherRAILROAD MEDICARE
AZ192828Medicaid
CO63334526Medicaid
UT1770556037Medicaid
WA1417983792Medicaid
AZ192828Medicaid