Healthcare Provider Details

I. General information

NPI: 1386623171
Provider Name (Legal Business Name): MILTON JOSEPH GRISHAM JR. D.O
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/11/2006
Last Update Date: 03/09/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2841 RENDOVA ROAD
SAN DIEGO CA
92155-5490
US

IV. Provider business mailing address

11823 MERIDEN LN
SAN DIEGO CA
92128-4335
US

V. Phone/Fax

Practice location:
  • Phone: 619-437-2117
  • Fax: 619-437-2700
Mailing address:
  • Phone: 858-208-8351
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number51683
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: