Provider Demographics
NPI:1427026947
Name:GRIZZLE, TROY GLENN (IDC)
Entity Type:Individual
Prefix:MR
First Name:TROY
Middle Name:GLENN
Last Name:GRIZZLE
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7791 MERCURY RD
Mailing Address - Street 2:
Mailing Address - City:TINKER AFB
Mailing Address - State:OK
Mailing Address - Zip Code:73145-8713
Mailing Address - Country:US
Mailing Address - Phone:405-739-3993
Mailing Address - Fax:
Practice Address - Street 1:7791 MERCURY RD
Practice Address - Street 2:
Practice Address - City:TINKER AFB
Practice Address - State:OK
Practice Address - Zip Code:73145-8713
Practice Address - Country:US
Practice Address - Phone:405-739-3993
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1710I1002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman