Provider Demographics
NPI:1427417062
Name:GRISHAM, JUSTIN (DO)
Entity Type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:
Last Name:GRISHAM
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1650 COCHRANE CIR
Mailing Address - Street 2:
Mailing Address - City:FT CARSON
Mailing Address - State:CO
Mailing Address - Zip Code:80913-4613
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1650 COCHRANE CIR
Practice Address - Street 2:
Practice Address - City:FT CARSON
Practice Address - State:CO
Practice Address - Zip Code:80913-4613
Practice Address - Country:US
Practice Address - Phone:801-815-0920
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-10
Last Update Date:2023-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR.0065361207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine