Healthcare Provider Details

I. General information

NPI: 1821166992
Provider Name (Legal Business Name): MARTIN GRIGLAK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/30/2006
Last Update Date: 06/27/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9888 GENESEE AVE
LA JOLLA CA
92037-1205
US

IV. Provider business mailing address

PO BOX 661687
ARCADIA CA
91066-1687
US

V. Phone/Fax

Practice location:
  • Phone: 858-626-6151
  • Fax:
Mailing address:
  • Phone: 626-447-0296
  • Fax: 626-447-6057

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License NumberG045747
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: