Provider Demographics
NPI:1932102159
Name:GRIGG, JOHNSIE CAROL (MD)
Entity Type:Individual
Prefix:
First Name:JOHNSIE
Middle Name:CAROL
Last Name:GRIGG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:CAROL
Other - Middle Name:
Other - Last Name:GRIGG
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 9671
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32120-9671
Mailing Address - Country:US
Mailing Address - Phone:386-676-7130
Mailing Address - Fax:386-676-7125
Practice Address - Street 1:1340 RIDGEWOOD AVE
Practice Address - Street 2:
Practice Address - City:HOLLY HILL
Practice Address - State:FL
Practice Address - Zip Code:32117-2320
Practice Address - Country:US
Practice Address - Phone:386-676-7130
Practice Address - Fax:386-676-7125
Is Sole Proprietor?:No
Enumeration Date:2005-05-23
Last Update Date:2012-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME47294207Q00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL04633OtherBLUE CROSS BLUE SHIELD
FLP00149413OtherRAILROAD MEDICARE
FLB03795Medicare UPIN
FL04633YMedicare ID - Type Unspecified