Healthcare Provider Details

I. General information

NPI: 1306861430
Provider Name (Legal Business Name): GARY T GRIMES M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/12/2006
Last Update Date: 06/27/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1720 E CESAR E CHAVEZ AVE
LOS ANGELES CA
90033-2414
US

IV. Provider business mailing address

210 N TUSTIN AVE
SANTA ANA CA
92705-3807
US

V. Phone/Fax

Practice location:
  • Phone: 323-268-5000
  • Fax: 714-647-1243
Mailing address:
  • Phone: 714-347-1000
  • Fax: 714-647-1250

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberG28362
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: