Provider Demographics
NPI:1396921474
Name:MANUEL GRIEGO, JR. D.O., P.A.
Entity type:Organization
Organization Name:MANUEL GRIEGO, JR. D.O., P.A.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MANUEL
Authorized Official - Middle Name:
Authorized Official - Last Name:GRIEGO
Authorized Official - Suffix:JR
Authorized Official - Credentials:DO
Authorized Official - Phone:214-580-7277
Mailing Address - Street 1:2701 S HAMPTON RD STE 104
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75224-2363
Mailing Address - Country:US
Mailing Address - Phone:214-330-9221
Mailing Address - Fax:214-231-2221
Practice Address - Street 1:1412 MAIN ST
Practice Address - Street 2:SUITE 905
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75202-4014
Practice Address - Country:US
Practice Address - Phone:214-580-7277
Practice Address - Fax:214-580-7283
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-18
Last Update Date:2008-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF1604208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXF1604OtherTX MEDICAL LICENSE
TX80266201Medicaid
TX80266201Medicaid
TXE26327Medicare UPIN