Provider Demographics
NPI:1982681599
Name:GRISE, DAVID (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:GRISE
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 1:30 JORDAN LN
Mailing Address - Street 2:PRIME HEALTHCARE
Mailing Address - City:WETHERSFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06109-1278
Mailing Address - Country:US
Mailing Address - Phone:860-263-0253
Mailing Address - Fax:860-263-0262
Practice Address - Street 1:27 SYCAMORE ST
Practice Address - Street 2:STE 100, PRIME HEALTHCARE
Practice Address - City:GLASTONBURY
Practice Address - State:CT
Practice Address - Zip Code:06033-2223
Practice Address - Country:US
Practice Address - Phone:860-659-0581
Practice Address - Fax:860-652-3077
Is Sole Proprietor?:No
Enumeration Date:2005-12-23
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT017362207R00000X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT010017362CT01OtherBCBS
CT001173624Medicaid
CT017362OtherMEDICAL LICENSE
CT017362OtherMEDICAL LICENSE
CT110006957Medicare ID - Type Unspecified
CT001173624Medicaid