Provider Demographics
NPI:1063613628
Name:GRIGOROV, MARAT (DO)
Entity type:Individual
Prefix:DR
First Name:MARAT
Middle Name:
Last Name:GRIGOROV
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:609 W MAPLE AVE
Mailing Address - Street 2:
Mailing Address - City:SPRINGDALE
Mailing Address - State:AR
Mailing Address - Zip Code:72764-5335
Mailing Address - Country:US
Mailing Address - Phone:479-757-8099
Mailing Address - Fax:479-757-2998
Practice Address - Street 1:333 TAMIAMI TRL S STE 397
Practice Address - Street 2:
Practice Address - City:VENICE
Practice Address - State:FL
Practice Address - Zip Code:34285-2442
Practice Address - Country:US
Practice Address - Phone:941-483-4000
Practice Address - Fax:941-480-1086
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-30
Last Update Date:2019-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS15600207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Single Specialty