Provider Demographics
NPI:1588684831
Name:GRISTE, JD (MD)
Entity Type:Individual
Prefix:DR
First Name:JD
Middle Name:
Last Name:GRISTE
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 1:1640 HOSPITAL DR
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-4754
Mailing Address - Country:US
Mailing Address - Phone:505-983-9350
Mailing Address - Fax:505-955-8763
Practice Address - Street 1:1640 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-4754
Practice Address - Country:US
Practice Address - Phone:505-983-9350
Practice Address - Fax:505-955-8763
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2008-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM94-2582085N0700X, 2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiology
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM20568Medicaid
300106788Medicare PIN
300043075Medicare PIN
NM20568Medicaid