Provider Demographics
NPI:1588827109
Name:GRIFFIN, SHANTA L (DPM)
Entity Type:Individual
Prefix:
First Name:SHANTA
Middle Name:L
Last Name:GRIFFIN
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 21
Mailing Address - Street 2:
Mailing Address - City:SOUTHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:38671-0001
Mailing Address - Country:US
Mailing Address - Phone:901-500-5103
Mailing Address - Fax:901-310-9117
Practice Address - Street 1:1750 MADISON AVE
Practice Address - Street 2:SUITE 260
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38104-6492
Practice Address - Country:US
Practice Address - Phone:901-500-5103
Practice Address - Fax:901-310-9117
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-03
Last Update Date:2022-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR252213E00000X
GAPOD001121213ES0103X
TN711213E00000X, 213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1521566Medicaid
TN103I482540OtherMEDICARE PTAN