Provider Demographics
NPI:1063611762
Name:GRISALES, TAMARA (MD)
Entity type:Individual
Prefix:DR
First Name:TAMARA
Middle Name:
Last Name:GRISALES
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:TAMARA
Other - Middle Name:G
Other - Last Name:HARTSHORN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5767 W CENTURY BLVD
Mailing Address - Street 2:SUITE 400
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90045-5631
Mailing Address - Country:US
Mailing Address - Phone:310-301-8707
Mailing Address - Fax:
Practice Address - Street 1:200 UCLA MEDICAL PLZ STE 140
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90095-1437
Practice Address - Country:US
Practice Address - Phone:310-794-7274
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-12
Last Update Date:2024-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA108105207VF0040X, 207V00000X, 207VF0040X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VF0040XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyUrogynecology and Reconstructive Pelvic Surgery
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology