Provider Demographics
NPI:1770565566
Name:GRILLO, ROBERT A JR (MD)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:A
Last Name:GRILLO
Suffix:JR
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 1:1 WAHOO AVE
Mailing Address - Street 2:
Mailing Address - City:GROTON
Mailing Address - State:CT
Mailing Address - Zip Code:06349-2324
Mailing Address - Country:US
Mailing Address - Phone:860-694-4966
Mailing Address - Fax:860-694-3388
Practice Address - Street 1:1 WAHOO AVE
Practice Address - Street 2:
Practice Address - City:GROTON
Practice Address - State:CT
Practice Address - Zip Code:06349-2324
Practice Address - Country:US
Practice Address - Phone:860-694-4966
Practice Address - Fax:860-694-3388
Is Sole Proprietor?:No
Enumeration Date:2005-11-17
Last Update Date:2023-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT264882084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001264887Medicaid
CT001264887Medicaid
CT26002306Medicare ID - Type Unspecified