Provider Demographics
NPI:1740369636
Name:GRIGORY, SCOTT MARTIN (MD)
Entity type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:MARTIN
Last Name:GRIGORY
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:ONE WEST MAIN
Mailing Address - Street 2:SUITE 100
Mailing Address - City:IDABEL
Mailing Address - State:OK
Mailing Address - Zip Code:74745-4655
Mailing Address - Country:US
Mailing Address - Phone:580-286-1101
Mailing Address - Fax:580-286-5566
Practice Address - Street 1:1 W MAIN ST
Practice Address - Street 2:SUITE 100
Practice Address - City:IDABEL
Practice Address - State:OK
Practice Address - Zip Code:74745-4654
Practice Address - Country:US
Practice Address - Phone:580-579-3385
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-03
Last Update Date:2015-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK25241208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200097850AMedicaid