Healthcare Provider Details

I. General information

NPI: 1982910741
Provider Name (Legal Business Name): JOHN A GRIMALDI DO INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/31/2010
Last Update Date: 01/12/2023
Certification Date: 01/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

450 4TH AVE SUTIE 312
CHULA VISTA CA
91910-4426
US

IV. Provider business mailing address

450 4TH AVE SUTIE 312
CHULA VISTA CA
91910-4426
US

V. Phone/Fax

Practice location:
  • Phone: 619-420-0201
  • Fax:
Mailing address:
  • Phone: 619-420-0201
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number20A11355
License Number StateCA

VIII. Authorized Official

Name: JOHN A GRIMALDI
Title or Position: PRESIDENT
Credential: DO
Phone: 619-420-0201