Healthcare Provider Details

I. General information

NPI: 1689940793
Provider Name (Legal Business Name): JOSEPH GRILLO DPM PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/23/2012
Last Update Date: 06/13/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14391 METROPOLIS AVE SUITE 104
FORT MYERS FL
33912-4421
US

IV. Provider business mailing address

14391 METROPOLIS AVE SUITE 104
FORT MYERS FL
33912-4421
US

V. Phone/Fax

Practice location:
  • Phone: 239-931-3668
  • Fax: 239-333-3669
Mailing address:
  • Phone: 239-931-3668
  • Fax: 239-333-3669

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License NumberPO 2106
License Number StateFL

VIII. Authorized Official

Name: DR. JOSEPH GRILLO
Title or Position: OWNER
Credential: DPM
Phone: 239-931-3668