Healthcare Provider Details

I. General information

NPI: 1740369636
Provider Name (Legal Business Name): SCOTT MARTIN GRIGORY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/03/2006
Last Update Date: 10/13/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 W MAIN ST SUITE 100
IDABEL OK
74745-4654
US

IV. Provider business mailing address

ONE WEST MAIN SUITE 100
IDABEL OK
74745-4655
US

V. Phone/Fax

Practice location:
  • Phone: 580-579-3385
  • Fax:
Mailing address:
  • Phone: 580-286-1101
  • Fax: 580-286-5566

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number25241
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: