Provider Demographics
NPI:1568467413
Name:GRISOLI, RICHARD J (MD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:J
Last Name:GRISOLI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:93 BOGUE FALAYA DR
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:LA
Mailing Address - Zip Code:70433-4303
Mailing Address - Country:US
Mailing Address - Phone:985-230-6688
Mailing Address - Fax:985-230-6176
Practice Address - Street 1:15790 PAUL VEGA MD DR
Practice Address - Street 2:
Practice Address - City:HAMMOND
Practice Address - State:LA
Practice Address - Zip Code:70403-1434
Practice Address - Country:US
Practice Address - Phone:985-345-8867
Practice Address - Fax:985-542-5322
Is Sole Proprietor?:No
Enumeration Date:2005-06-16
Last Update Date:2017-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA016201207L00000X, 207LC0200X
FLME92186202K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No207LC0200XAllopathic & Osteopathic PhysiciansAnesthesiologyCritical Care Medicine
No202K00000XAllopathic & Osteopathic PhysiciansPhlebology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1337781Medicaid
LA1337781Medicaid
B64276Medicare UPIN
LA52963BC06Medicare PIN