Healthcare Provider Details

I. General information

NPI: 1760483796
Provider Name (Legal Business Name): JOSEPH GRILLO DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/01/2005
Last Update Date: 12/15/2020
Certification Date: 12/15/2020
Deactivation Date: 12/10/2020
Reactivation Date: 12/15/2020

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: 239-333-0746
Mailing address:
  • Phone: 239-931-3668
  • Fax: 239-333-0746

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:
Title or Position:
Credential:
Phone: