Healthcare Provider Details

I. General information

NPI: 1306344932
Provider Name (Legal Business Name): MATTHEW GRIMES DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/29/2018
Last Update Date: 04/10/2023
Certification Date: 05/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

620 JOHN PAUL JONES CIR
PORTSMOUTH VA
23708-2111
US

IV. Provider business mailing address

2496 BAUER ROAD
SAN DIEGO CA
92145-0001
US

V. Phone/Fax

Practice location:
  • Phone: 757-953-5000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number0102205742
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: