Healthcare Provider Details

I. General information

NPI: 1720062789
Provider Name (Legal Business Name): JOHN ANTHONY GRISWOLD JR. M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/02/2005
Last Update Date: 11/23/2021
Certification Date: 11/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3601 4TH ST
LUBBOCK TX
79430-0002
US

IV. Provider business mailing address

PO BOX 5865
LUBBOCK TX
79408-5865
US

V. Phone/Fax

Practice location:
  • Phone: 806-743-2373
  • Fax: 806-743-4354
Mailing address:
  • Phone: 806-743-2898
  • Fax: 806-743-2787

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberG1419
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code2086S0102X
TaxonomySurgical Critical Care Physician
License NumberG1419
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: