Provider Demographics
NPI:1770579658
Name:GRIGERA, FERNANDO (MD)
Entity type:Individual
Prefix:DR
First Name:FERNANDO
Middle Name:
Last Name:GRIGERA
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 4168
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83205-4168
Mailing Address - Country:US
Mailing Address - Phone:208-234-2001
Mailing Address - Fax:208-232-2195
Practice Address - Street 1:777 HOSPITAL WAY BLDG A
Practice Address - Street 2:STE. 101
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-2753
Practice Address - Country:US
Practice Address - Phone:208-234-2001
Practice Address - Fax:208-232-2195
Is Sole Proprietor?:No
Enumeration Date:2005-09-26
Last Update Date:2011-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM9142207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID806974000Medicaid
ID806974000Medicaid
ID1128224Medicare ID - Type Unspecified