Provider Demographics
NPI:1568140713
Name:GRIMES, MARK JASON II (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:JASON
Last Name:GRIMES
Suffix:II
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 1:2105 N PARKWAY ST
Mailing Address - Street 2:
Mailing Address - City:CORINTH
Mailing Address - State:MS
Mailing Address - Zip Code:38834-2836
Mailing Address - Country:US
Mailing Address - Phone:912-288-5687
Mailing Address - Fax:
Practice Address - Street 1:611 ALCORN DR
Practice Address - Street 2:
Practice Address - City:CORINTH
Practice Address - State:MS
Practice Address - Zip Code:38834-9388
Practice Address - Country:US
Practice Address - Phone:662-293-1000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-07
Last Update Date:2023-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MST-5116207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty