Provider Demographics
NPI:1063404051
Name:GRISAITIS, WILLIAM J (MD)
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:J
Last Name:GRISAITIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:331 N MAITLAND AVE
Mailing Address - Street 2:BUILDING A SUITE 5
Mailing Address - City:MAITLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32751-4762
Mailing Address - Country:US
Mailing Address - Phone:407-644-9030
Mailing Address - Fax:407-644-9440
Practice Address - Street 1:331 N MAITLAND AVE
Practice Address - Street 2:BUILDING A SUITE 5
Practice Address - City:MAITLAND
Practice Address - State:FL
Practice Address - Zip Code:32751-4762
Practice Address - Country:US
Practice Address - Phone:407-644-9030
Practice Address - Fax:407-644-9440
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0035814207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
D57090Medicare UPIN
FL59986Medicare ID - Type Unspecified