Provider Demographics
NPI:1801137682
Name:GRIMALDI, ALEXANDER ANTONIO (DO)
Entity type:Individual
Prefix:
First Name:ALEXANDER
Middle Name:ANTONIO
Last Name:GRIMALDI
Suffix:
Gender:M
Credentials:DO
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 3308
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3308
Mailing Address - Country:US
Mailing Address - Phone:503-215-1314
Mailing Address - Fax:
Practice Address - Street 1:2333 BIDDLE AVE
Practice Address - Street 2:
Practice Address - City:WYANDOTTE
Practice Address - State:MI
Practice Address - Zip Code:48192-4668
Practice Address - Country:US
Practice Address - Phone:734-246-6000
Practice Address - Fax:734-246-8795
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-04
Last Update Date:2017-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI390200000X
ORDO182179207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program