Healthcare Provider Details

I. General information

NPI: 1366979007
Provider Name (Legal Business Name): JORDAN GRILLIOT D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/12/2017
Last Update Date: 10/06/2026
Certification Date: 10/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 AVIATOR CT STE 210
VANDALIA OH
45377-9475
US

IV. Provider business mailing address

2211 NORTHBRIDGE TRL
TROY OH
45373-4667
US

V. Phone/Fax

Practice location:
  • Phone: 937-832-4773
  • Fax: 937-832-2986
Mailing address:
  • Phone: 937-626-3110
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number34.016569
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number330890
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: