Provider Demographics
NPI:1356531180
Name:GRISHAM, C. KEITH (MD)
Entity type:Individual
Prefix:DR
First Name:C.
Middle Name:KEITH
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 1:3108 MIDWAY RD
Mailing Address - Street 2:SUITE #200
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75093-6383
Mailing Address - Country:US
Mailing Address - Phone:972-781-1515
Mailing Address - Fax:972-781-1313
Practice Address - Street 1:3108 MIDWAY RD
Practice Address - Street 2:SUITE #200
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75093-6383
Practice Address - Country:US
Practice Address - Phone:972-781-1515
Practice Address - Fax:972-781-1313
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-27
Last Update Date:2008-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK9791207VX0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX030393501Medicaid