Provider Demographics
NPI:1760787444
Name:GRIVAS, TANIA (MD)
Entity Type:Individual
Prefix:DR
First Name:TANIA
Middle Name:
Last Name:GRIVAS
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 1:17 VIA SEVILLA
Mailing Address - Street 2:
Mailing Address - City:ROLLING HILLS ESTATES
Mailing Address - State:CA
Mailing Address - Zip Code:90274-3425
Mailing Address - Country:US
Mailing Address - Phone:310-378-2740
Mailing Address - Fax:
Practice Address - Street 1:17 VIA SEVILLA
Practice Address - Street 2:
Practice Address - City:ROLLING HILLS ESTATES
Practice Address - State:CA
Practice Address - Zip Code:90274-3425
Practice Address - Country:US
Practice Address - Phone:310-293-9994
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-01-11
Last Update Date:2014-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA53360208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery