Provider Demographics
NPI:1598789513
Name:GRISSOM, JOHN THOMAS II (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:THOMAS
Last Name:GRISSOM
Suffix:II
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:J
Other - Middle Name:THOMAS
Other - Last Name:GRISSOM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 951027
Mailing Address - Street 2:
Mailing Address - City:SOUTH JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84095-1027
Mailing Address - Country:US
Mailing Address - Phone:907-373-9460
Mailing Address - Fax:907-373-9461
Practice Address - Street 1:3066 E MERIDIAN PARK LOOP # 1
Practice Address - Street 2:
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654-7299
Practice Address - Country:US
Practice Address - Phone:907-373-9460
Practice Address - Fax:907-373-9461
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2012-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-7402208VP0014X
AK6558207L00000X, 208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKMD0853Medicaid
IDE91206Medicare UPIN
1138383Medicare ID - Type Unspecified
AKMD0853Medicaid
AK162381Medicare PIN