MEDICARE: MISTI GRIMSON M.D.

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	207Q00000X	Family Medicine Physician	35082326G	OH

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	8BN462	OTHER	TX	BCBS

General Provider Information

NPI Number	:	1619960127
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISTI GRIMSON M.D.

Provider Business Mailing Address
First Line	:	4001 WORTH ST
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75246-1608
Country	:	US
Telephone Number	:	214-828-1745
Fax Number	:	214-828-1734

Provider Business Practice Location Address
First Line	:	4001 WORTH ST
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75246-1608
Country	:	US
Telephone Number	:	214-828-1745
Fax Number	:	214-828-1734

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

Provider Enumeration Date	:	08/30/2005
Last Update Date	:	02/24/2011

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Directions to “ MISTI GRIMSON M.D.” Practice Location

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