Provider Demographics
NPI:1245290048
Name:GRISHAM, DONALD WESLEY (MD)
Entity type:Individual
Prefix:
First Name:DONALD
Middle Name:WESLEY
Last Name:GRISHAM
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 1:1100 ENGLAND DR
Mailing Address - Street 2:
Mailing Address - City:COOKEVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38501-0924
Mailing Address - Country:US
Mailing Address - Phone:931-528-7531
Mailing Address - Fax:931-372-2756
Practice Address - Street 1:1100 ENGLAND DR
Practice Address - Street 2:
Practice Address - City:COOKEVILLE
Practice Address - State:TN
Practice Address - Zip Code:38501-0924
Practice Address - Country:US
Practice Address - Phone:931-528-7531
Practice Address - Fax:931-372-2756
Is Sole Proprietor?:No
Enumeration Date:2006-03-24
Last Update Date:2023-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN15257207R00000X
TNMD15257208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNA99051Medicare UPIN
TN3026663Medicare ID - Type Unspecified