Provider Demographics
NPI:1245307735
Name:GRIFFIN, GARY S (MD)
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:S
Last Name:GRIFFIN
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:PO BOX 1483
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31902-1483
Mailing Address - Country:US
Mailing Address - Phone:706-880-7366
Mailing Address - Fax:706-880-7299
Practice Address - Street 1:1600 VERNON RD
Practice Address - Street 2:SUITE G
Practice Address - City:LAGRANGE
Practice Address - State:GA
Practice Address - Zip Code:30240-4143
Practice Address - Country:US
Practice Address - Phone:706-880-7366
Practice Address - Fax:706-880-7299
Is Sole Proprietor?:No
Enumeration Date:2006-11-29
Last Update Date:2017-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT2788561205207RG0300X
GA044731207R00000X, 207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTG20480Medicare UPIN
G20480Medicare UPIN
UT005745020Medicare ID - Type Unspecified