Healthcare Provider Details

I. General information

NPI: 1043385131
Provider Name (Legal Business Name): TONYA GRISSAM MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: TONYA MONIQUE GRISSAM

II. Dates (important events)

Enumeration Date: 11/22/2006
Last Update Date: 01/01/2026
Certification Date: 01/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6451 N FEDERAL HWY STE 800
FORT LAUDERDALE FL
33308-1409
US

IV. Provider business mailing address

6451 N FEDERAL HWY STE 800
FORT LAUDERDALE FL
33308-1409
US

V. Phone/Fax

Practice location:
  • Phone: 800-586-5022
  • Fax: 954-229-9801
Mailing address:
  • Phone: 800-586-5022
  • Fax: 954-229-9801

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number4301106345
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number051567
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: