Provider Demographics
NPI:1659597193
Name:GRIESBACH, AUDREY (MD)
Entity Type:Individual
Prefix:
First Name:AUDREY
Middle Name:
Last Name:GRIESBACH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11835 W OLYMPIC BLVD
Mailing Address - Street 2:SUITE 1200E
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90064-5001
Mailing Address - Country:US
Mailing Address - Phone:310-996-8990
Mailing Address - Fax:310-996-8991
Practice Address - Street 1:11835 W OLYMPIC BLVD
Practice Address - Street 2:SUITE 1200E
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90064-5001
Practice Address - Country:US
Practice Address - Phone:310-996-8990
Practice Address - Fax:310-996-8991
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG351422080P0006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0006XAllopathic & Osteopathic PhysiciansPediatricsDevelopmental - Behavioral Pediatrics