Provider Demographics
NPI:1902833742
Name:GRIMALDOS, JUAN PABLO (MD)
Entity Type:Individual
Prefix:
First Name:JUAN
Middle Name:PABLO
Last Name:GRIMALDOS
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 99371
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76199-0371
Mailing Address - Country:US
Mailing Address - Phone:682-885-1855
Mailing Address - Fax:682-885-7347
Practice Address - Street 1:801 7TH AVE
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-2733
Practice Address - Country:US
Practice Address - Phone:682-885-4054
Practice Address - Fax:682-885-7497
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2012-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME85392207L00000X
TXL4406207L00000X, 207LP3000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP3000XAllopathic & Osteopathic PhysiciansAnesthesiologyPediatric Anesthesiology
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX152965306OtherCSHCN
FL271316100Medicaid
TX152965304OtherCSHCN
TX152965305Medicaid
TX137345809OtherMEDICAID GROUP NUMBER
TX140442853OtherCSHCN GROUP NUMBER
TX137345809OtherMEDICAID GROUP NUMBER
FL271316100Medicaid
TX152965305Medicaid