MEDICARE: MICHELINA DE LA MAZA GRIMES 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	2080P0207X	Pediatric Hematology & Oncology Physician	52155	AZ
2	208000000X	Pediatrics Physician	52125	AZ

General Provider Information

NPI Number	:	1255779385
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHELINA DE LA MAZA GRIMES MD

Provider Business Mailing Address
First Line	:	1625 N CAMPBELL AVE
Second Line	:
City	:	TUCSON
State	:	AZ
Zip	:	85719-4330
Country	:	US
Telephone Number	:	520-626-7053
Fax Number	:	520-626-6986

Provider Business Practice Location Address
First Line	:	1625 N CAMPBELL AVE
Second Line	:
City	:	TUCSON
State	:	AZ
Zip	:	85719
Country	:	US
Telephone Number	:	520-626-7053
Fax Number	:	520-626-6986

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

Provider Enumeration Date	:	06/11/2013
Last Update Date	:	02/25/2026

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