Healthcare Provider Details

I. General information

NPI: 1063611762
Provider Name (Legal Business Name): TAMARA GRISALES M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: DR. TAMARA G. HARTSHORN

II. Dates (important events)

Enumeration Date: 07/12/2007
Last Update Date: 10/15/2024
Certification Date: 10/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 UCLA MEDICAL PLZ STE 140
LOS ANGELES CA
90095-1437
US

IV. Provider business mailing address

5767 W CENTURY BLVD SUITE 400
LOS ANGELES CA
90045-5631
US

V. Phone/Fax

Practice location:
  • Phone: 310-794-7274
  • Fax:
Mailing address:
  • Phone: 310-301-8707
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207VF0040X
TaxonomyUrogynecology and Reconstructive Pelvic Surgery (Obstetrics & Gynecology) Physician
License NumberA108105
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberA108105
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: