Provider Demographics
NPI:1609830009
Name:GRIMSLEY, BRADLEY R (MD)
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:R
Last Name:GRIMSLEY
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 1:621 N HALL ST
Mailing Address - Street 2:STE 100
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75226-1339
Mailing Address - Country:US
Mailing Address - Phone:214-821-9600
Mailing Address - Fax:214-823-5449
Practice Address - Street 1:621 N HALL ST
Practice Address - Street 2:STE 100
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75226-1339
Practice Address - Country:US
Practice Address - Phone:214-821-9600
Practice Address - Fax:214-823-5449
Is Sole Proprietor?:No
Enumeration Date:2006-04-13
Last Update Date:2022-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK8184174400000X, 2086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXG21163Medicare UPIN