Provider Demographics
NPI:1902217581
Name:GRISBAUM, GARIC (MD)
Entity Type:Individual
Prefix:
First Name:GARIC
Middle Name:
Last Name:GRISBAUM
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 1:4512 ORLEANS BLVD
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON
Mailing Address - State:LA
Mailing Address - Zip Code:70121-1224
Mailing Address - Country:US
Mailing Address - Phone:504-905-8970
Mailing Address - Fax:
Practice Address - Street 1:900 WILKINSON ST
Practice Address - Street 2:
Practice Address - City:MANDEVILLE
Practice Address - State:LA
Practice Address - Zip Code:70448-3533
Practice Address - Country:US
Practice Address - Phone:985-624-4450
Practice Address - Fax:985-624-4461
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-16
Last Update Date:2024-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA3079052084P0800X
MS239822084A0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084A0401XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction Medicine
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry