Healthcare Provider Details

I. General information

NPI: 1255396073
Provider Name (Legal Business Name): JOHN DALE GRIZZLE II M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/18/2006
Last Update Date: 10/15/2025
Certification Date: 10/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15800 S WESTERN AVE
OKLAHOMA CITY OK
73170-9393
US

IV. Provider business mailing address

15800 S WESTERN AVE
OKLAHOMA CITY OK
73170-9393
US

V. Phone/Fax

Practice location:
  • Phone: 405-793-1300
  • Fax: 405-805-6611
Mailing address:
  • Phone: 405-793-1300
  • Fax: 405-805-6611

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number20170
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number20170
License Number StateOK
# 3
Primary TaxonomyN
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number20170
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: