Provider Demographics
NPI:1700812724
Name:GRIFFIN, JEANNINE L (MD)
Entity Type:Individual
Prefix:DR
First Name:JEANNINE
Middle Name:L
Last Name:GRIFFIN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 NORTH VIRGINIA
Mailing Address - Street 2:
Mailing Address - City:PORT LAVACA
Mailing Address - State:TX
Mailing Address - Zip Code:77979
Mailing Address - Country:US
Mailing Address - Phone:361-552-6721
Mailing Address - Fax:361-552-7463
Practice Address - Street 1:1200 NORTH VIRGINIA
Practice Address - Street 2:
Practice Address - City:PORT LAVACA
Practice Address - State:TX
Practice Address - Zip Code:77979
Practice Address - Country:US
Practice Address - Phone:361-552-6721
Practice Address - Fax:361-552-7463
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2014-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG5119208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX113513502OtherGROUP MEDICAID NUMBER
TX118203202Medicaid
TXZOO0H160OtherGROUP MEDICARE NUMBER
TX118203202Medicaid
TX113513502OtherGROUP MEDICAID NUMBER