MEDICARE: TONYA GRISSAM MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208000000X	Pediatrics Physician	4301106345	MI
2	208000000X	Pediatrics Physician	051567	GA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1043385131
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TONYA GRISSAM MD

Provider Business Mailing Address
First Line	:	6451 N FEDERAL HWY STE 800
Second Line	:
City	:	FORT LAUDERDALE
State	:	FL
Zip	:	33308-1409
Country	:	US
Telephone Number	:	800-586-5022
Fax Number	:	954-229-9801

Provider Business Practice Location Address
First Line	:	6451 N FEDERAL HWY STE 800
Second Line	:
City	:	FORT LAUDERDALE
State	:	FL
Zip	:	33308-1409
Country	:	US
Telephone Number	:	800-586-5022
Fax Number	:	954-229-9801

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/22/2006
Last Update Date	:	01/01/2026

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Directions to “ TONYA GRISSAM MD” Practice Location

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