Provider Demographics
NPI:1922172089
Name:GRIMES, GARY AUSTIN (MD)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:AUSTIN
Last Name:GRIMES
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 1:39749 MAKIN AVE
Mailing Address - Street 2:
Mailing Address - City:PALMDALE
Mailing Address - State:CA
Mailing Address - Zip Code:93551-2940
Mailing Address - Country:US
Mailing Address - Phone:818-542-8677
Mailing Address - Fax:661-267-0905
Practice Address - Street 1:39749 MAKIN AVE
Practice Address - Street 2:
Practice Address - City:PALMDALE
Practice Address - State:CA
Practice Address - Zip Code:93551-2940
Practice Address - Country:US
Practice Address - Phone:661-267-0777
Practice Address - Fax:661-267-0905
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-20
Last Update Date:2010-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA45278207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
756053859OtherTRAVELERS CARE
E62889Medicare UPIN
756053859OtherTRAVELERS CARE