Provider Demographics
NPI:1750516035
Name:GRIGG GUTIERREZ, NICOLE M (MD)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:M
Last Name:GRIGG GUTIERREZ
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 1:512 VICTORIA LN STE 2
Mailing Address - Street 2:
Mailing Address - City:HARLINGEN
Mailing Address - State:TX
Mailing Address - Zip Code:78550-3227
Mailing Address - Country:US
Mailing Address - Phone:956-365-4400
Mailing Address - Fax:956-365-4111
Practice Address - Street 1:512 VICTORIA LN STE 2
Practice Address - Street 2:
Practice Address - City:HARLINGEN
Practice Address - State:TX
Practice Address - Zip Code:78550-3227
Practice Address - Country:US
Practice Address - Phone:956-365-4400
Practice Address - Fax:956-365-4111
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-15
Last Update Date:2021-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2015-00773207R00000X
PR18392207R00000X
TXQ7052207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNC2408Medicaid
NC1750516035Medicaid
SCNC2408Medicaid
NCNCO307AMedicare PIN