Provider Demographics
NPI:1134787997
Name:GRIFFIN, KADARIUS CORRELL
Entity type:Individual
Prefix:
First Name:KADARIUS
Middle Name:CORRELL
Last Name:GRIFFIN
Suffix:
Gender:M
Credentials:
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 3477
Mailing Address - Street 2:
Mailing Address - City:OAK PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60303-3477
Mailing Address - Country:US
Mailing Address - Phone:708-548-9308
Mailing Address - Fax:
Practice Address - Street 1:11411 N LINCOLN BLVD
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73114-7647
Practice Address - Country:US
Practice Address - Phone:708-548-9308
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-05
Last Update Date:2019-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILU0938874903OtherCIGNA