Provider Demographics
NPI:1013974468
Name:GRISHAM, DANNETTA (MD)
Entity Type:Individual
Prefix:
First Name:DANNETTA
Middle Name:
Last Name:GRISHAM
Suffix:
Gender:F
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 241035
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72223-0001
Mailing Address - Country:US
Mailing Address - Phone:501-258-3073
Mailing Address - Fax:
Practice Address - Street 1:300 WERNER ST
Practice Address - Street 2:
Practice Address - City:HOT SPRINGS
Practice Address - State:AR
Practice Address - Zip Code:71913-6406
Practice Address - Country:US
Practice Address - Phone:501-622-1120
Practice Address - Fax:501-622-1199
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-28
Last Update Date:2008-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC7699207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
539876972OtherMEDICARE LINKED
AR117633001Medicaid
539876972OtherMEDICARE LINKED
AR53987Medicare ID - Type Unspecified