Provider Demographics
NPI:1619960127
Name:GRIMSON, MISTI (MD)
Entity type:Individual
Prefix:
First Name:MISTI
Middle Name:
Last Name:GRIMSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4001 WORTH ST
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75246-1608
Mailing Address - Country:US
Mailing Address - Phone:214-828-1745
Mailing Address - Fax:214-828-1734
Practice Address - Street 1:4001 WORTH ST
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75246-1608
Practice Address - Country:US
Practice Address - Phone:214-828-1745
Practice Address - Fax:214-828-1734
Is Sole Proprietor?:No
Enumeration Date:2005-08-30
Last Update Date:2011-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35082326G207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2426539Medicaid
TX198362901Medicaid
TX8BN462OtherBCBS
OH2426539Medicaid
TXP00699106Medicare PIN
TX8L4264Medicare PIN
OHI20274Medicare UPIN