Provider Demographics
NPI:1801898614
Name:GRIFFIN, VIVIAN D (MD)
Entity type:Individual
Prefix:DR
First Name:VIVIAN
Middle Name:D
Last Name:GRIFFIN
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:PO BOX 102222
Mailing Address - Street 2:ATTN: CREDENTIAL DEPARTMENT
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30368-2222
Mailing Address - Country:US
Mailing Address - Phone:239-274-8200
Mailing Address - Fax:239-278-3350
Practice Address - Street 1:9320 STATE ROAD 54
Practice Address - Street 2:
Practice Address - City:TRINITY
Practice Address - State:FL
Practice Address - Zip Code:34655-1808
Practice Address - Country:US
Practice Address - Phone:727-493-2513
Practice Address - Fax:877-917-2336
Is Sole Proprietor?:No
Enumeration Date:2005-08-11
Last Update Date:2023-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME991822085R0001X, 2085B0100X, 2085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Yes2085B0100XAllopathic & Osteopathic PhysiciansRadiologyBody Imaging
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL005945900Medicaid
ILK49392OtherMEDICARE-JOLIET
IN200223290Medicaid
IN000000550768OtherANTHEM
IN197130FOtherMEDICARE MERRILLVILLE
IN202980EOtherMEDICARE GARY
ILK49391OtherMEDICARE-BOURBONNAIS
ILK49391OtherMEDICARE-WATSEKA
IN202980EOtherMEDICARE GARY