Provider Demographics
NPI:1336200039
Name:GRISWOLD, MARK LESLIE (DO)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:LESLIE
Last Name:GRISWOLD
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 69610
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85737-0019
Mailing Address - Country:US
Mailing Address - Phone:520-797-9700
Mailing Address - Fax:520-797-0600
Practice Address - Street 1:1521 E TANGERINE RD
Practice Address - Street 2:SUITE 301
Practice Address - City:ORO VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:85755-6225
Practice Address - Country:US
Practice Address - Phone:520-797-9700
Practice Address - Fax:520-797-0600
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-13
Last Update Date:2007-11-27
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AZ2799207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ25131Medicare ID - Type Unspecified
AZE82039Medicare UPIN