Healthcare Provider Details

I. General information

NPI: 1588827109
Provider Name (Legal Business Name): SHANTA L. GRIFFIN DPM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/03/2008
Last Update Date: 05/03/2022
Certification Date: 05/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1750 MADISON AVE SUITE 260
MEMPHIS TN
38104-6492
US

IV. Provider business mailing address

PO BOX 21
SOUTHAVEN MS
38671-0001
US

V. Phone/Fax

Practice location:
  • Phone: 901-500-5103
  • Fax: 901-310-9117
Mailing address:
  • Phone: 901-500-5103
  • Fax: 901-310-9117

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number252
License Number StateAR
# 2
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberPOD001121
License Number StateGA
# 3
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number711
License Number StateTN
# 4
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number711
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: