Healthcare Provider Details

I. General information

NPI: 1184684581
Provider Name (Legal Business Name): DOUGLAS JAMES GRIDER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/28/2006
Last Update Date: 03/08/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1906 BELLEVIEW AVE SE
ROANOKE VA
24014-1838
US

IV. Provider business mailing address

PO BOX 21569
ROANOKE VA
24018-0568
US

V. Phone/Fax

Practice location:
  • Phone: 540-981-7271
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number0101247057
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License Number0101247057
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: