Provider Demographics
NPI:1134206147
Name:GRISSOM, MYRA CRANSHAW (MD)
Entity type:Individual
Prefix:MS
First Name:MYRA
Middle Name:CRANSHAW
Last Name:GRISSOM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MS
Other - First Name:MYRA
Other - Middle Name:LOUISE
Other - Last Name:CRANSHAW
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1314 RIGGS ST NW
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20009
Mailing Address - Country:US
Mailing Address - Phone:202-667-5527
Mailing Address - Fax:202-667-5561
Practice Address - Street 1:2817 12TH ST NE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20017
Practice Address - Country:US
Practice Address - Phone:202-526-1030
Practice Address - Fax:202-526-0230
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCMD21669208000000X
MDD0051418208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
491180Medicare ID - Type Unspecified
H55813Medicare UPIN