Provider Demographics
NPI:1750726857
Name:GRIGORYAN, GRIGOR (MD)
Entity type:Individual
Prefix:
First Name:GRIGOR
Middle Name:
Last Name:GRIGORYAN
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:PO BOX 10069
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92423-0069
Mailing Address - Country:US
Mailing Address - Phone:909-335-4188
Mailing Address - Fax:
Practice Address - Street 1:2 W FERN AVE
Practice Address - Street 2:
Practice Address - City:REDLANDS
Practice Address - State:CA
Practice Address - Zip Code:92373
Practice Address - Country:US
Practice Address - Phone:909-793-3311
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-02
Last Update Date:2019-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA134603207X00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program