Provider Demographics
NPI:1518959485
Name:GRISELL, DAVID LAWRENCE (DO)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:LAWRENCE
Last Name:GRISELL
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 1:209 CRESCENT AVE
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29605-2814
Mailing Address - Country:US
Mailing Address - Phone:864-436-7447
Mailing Address - Fax:
Practice Address - Street 1:209 CRESCENT AVE
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29605-2814
Practice Address - Country:US
Practice Address - Phone:864-436-7447
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-17
Last Update Date:2021-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC12602085R0001X
OH340082982085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200491700Medicaid
OH2478902Medicaid
KY64087455Medicaid
SC012603Medicaid
OHP00166987OtherRAILROAD MEDICARE
SCAA3832Medicare UPIN
OH2478902Medicaid
KY64087455Medicaid
OH08298OtherHUMANA
SCAA3832Medicare UPIN
OHF23660Medicare UPIN
OHGR4134671Medicare ID - Type Unspecified
OH2478902Medicaid
OHP00166987OtherRAILROAD MEDICARE