Provider Demographics
NPI:1518970847
Name:GRIVETTI, DAMIAN W (MD)
Entity Type:Individual
Prefix:DR
First Name:DAMIAN
Middle Name:W
Last Name:GRIVETTI
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 1:600 E 1ST ST
Mailing Address - Street 2:
Mailing Address - City:SPRING VALLEY
Mailing Address - State:IL
Mailing Address - Zip Code:61362-1512
Mailing Address - Country:US
Mailing Address - Phone:815-339-6245
Mailing Address - Fax:815-339-2617
Practice Address - Street 1:309 S. MCCOY
Practice Address - Street 2:
Practice Address - City:GRANVILLE
Practice Address - State:IL
Practice Address - Zip Code:61326-9333
Practice Address - Country:US
Practice Address - Phone:815-339-6245
Practice Address - Fax:815-339-2617
Is Sole Proprietor?:No
Enumeration Date:2006-08-15
Last Update Date:2008-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036109350207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036109350Medicaid
H91620Medicare UPIN