Provider Demographics
NPI:1922281385
Name:CHANDA A. GRIESSEL M.D., PLLC
Entity Type:Organization
Organization Name:CHANDA A. GRIESSEL M.D., PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHANDA
Authorized Official - Middle Name:ANNETTE
Authorized Official - Last Name:GRIESSEL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:336-760-2240
Mailing Address - Street 1:150 KIMEL PARK DR
Mailing Address - Street 2:SUITE 200
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-6992
Mailing Address - Country:US
Mailing Address - Phone:336-760-2240
Mailing Address - Fax:336-760-2239
Practice Address - Street 1:150 KIMEL PARK DR
Practice Address - Street 2:SUITE 200
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-6992
Practice Address - Country:US
Practice Address - Phone:336-760-2240
Practice Address - Fax:336-760-2239
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-07
Last Update Date:2012-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200301236207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5950669Medicaid