Provider Demographics
NPI:1861692725
Name:MANUEL GRIEGO JR DO PA
Entity type:Organization
Organization Name:MANUEL GRIEGO JR DO PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:CAROLE
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:BARNETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:214-580-7277
Mailing Address - Street 1:1421 MAIN STREET
Mailing Address - Street 2:SUITE 905
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75202
Mailing Address - Country:US
Mailing Address - Phone:214-580-7277
Mailing Address - Fax:
Practice Address - Street 1:700 N PEARL ST
Practice Address - Street 2:SUITE N208
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75201-2824
Practice Address - Country:US
Practice Address - Phone:214-999-9355
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-19
Last Update Date:2007-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF1604207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX80266201Medicaid
TX80266201Medicaid
TX0026CCMedicare PIN