Healthcare Provider Details

I. General information

NPI: 1932102159
Provider Name (Legal Business Name): JOHNSIE CAROL GRIGG M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CAROL GRIGG M.D.

II. Dates (important events)

Enumeration Date: 05/23/2005
Last Update Date: 06/21/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1340 RIDGEWOOD AVE
HOLLY HILL FL
32117-2320
US

IV. Provider business mailing address

PO BOX 9671
DAYTONA BEACH FL
32120-9671
US

V. Phone/Fax

Practice location:
  • Phone: 386-676-7130
  • Fax: 386-676-7125
Mailing address:
  • Phone: 386-676-7130
  • Fax: 386-676-7125

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberME47294
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberME47294
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: