Provider Demographics
NPI:1609817535
Name:PATISH, GRIGORIY N (DPM)
Entity Type:Individual
Prefix:DR
First Name:GRIGORIY
Middle Name:N
Last Name:PATISH
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:407 POTTER ST STE A
Mailing Address - Street 2:
Mailing Address - City:FALLBROOK
Mailing Address - State:CA
Mailing Address - Zip Code:92028-3086
Mailing Address - Country:US
Mailing Address - Phone:760-728-4800
Mailing Address - Fax:760-728-0061
Practice Address - Street 1:407 POTTER ST STE A
Practice Address - Street 2:
Practice Address - City:FALLBROOK
Practice Address - State:CA
Practice Address - Zip Code:92028-3086
Practice Address - Country:US
Practice Address - Phone:760-728-4800
Practice Address - Fax:760-728-0061
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-10
Last Update Date:2021-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYN005980213E00000X
NJ25MD00298800213E00000X
CAE4987213EP1101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02639412Medicaid
NY02639412Medicaid
NYPJ1291Medicare ID - Type Unspecified