Healthcare Provider Details

I. General information

NPI: 1598761736
Provider Name (Legal Business Name): JOSEPH GRILLO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2005
Last Update Date: 06/14/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1044 S.W. 44TH ST.
OKLAHOMA CITY OK
73109
US

IV. Provider business mailing address

1044 S.W. 44TH ST.
OKLAHOMA CITY OK
73109
US

V. Phone/Fax

Practice location:
  • Phone: 405-631-4263
  • Fax: 405-631-4820
Mailing address:
  • Phone: 405-631-4263
  • Fax: 405-616-2670

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XX0004X
TaxonomyOrthopaedic Foot and Ankle Surgery Physician
License Number12405
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: