Provider Demographics
NPI:1700836335
Name:GRISSON, ALLEN TRACY (MD)
Entity Type:Individual
Prefix:
First Name:ALLEN
Middle Name:TRACY
Last Name:GRISSON
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:PO BOX 5370
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75608-5370
Mailing Address - Country:US
Mailing Address - Phone:903-663-4800
Mailing Address - Fax:903-663-0378
Practice Address - Street 1:1204 N MOUND ST
Practice Address - Street 2:RADIOLOGY DEPARTMENT
Practice Address - City:NACOGDOCHES
Practice Address - State:TX
Practice Address - Zip Code:75961-4027
Practice Address - Country:US
Practice Address - Phone:936-568-8514
Practice Address - Fax:903-663-0378
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2011-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK35802085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX047351401Medicaid
G81353Medicare UPIN
TX047351401Medicaid