Provider Demographics
NPI:1255396073
Name:GRIZZLE, JOHN DALE II (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:DALE
Last Name:GRIZZLE
Suffix:II
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:5300 N INDEPENDENCE AVE STE 280
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73112-5555
Mailing Address - Country:US
Mailing Address - Phone:405-317-1266
Mailing Address - Fax:405-604-6007
Practice Address - Street 1:5701 N PORTLAND AVE STE 126
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73112-1673
Practice Address - Country:US
Practice Address - Phone:405-317-1266
Practice Address - Fax:405-604-6007
Is Sole Proprietor?:No
Enumeration Date:2006-04-18
Last Update Date:2018-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK20170207P00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK731381689GRIOtherPREMIERE
OK080136148OtherRAILROAD
OK100113130CMedicaid
OK244431002OtherMEDICARE ID
OK20170OtherLICENSE
OK25263OtherOBNDD
244234503Medicare PIN
OK20170OtherLICENSE