Provider Demographics
NPI:1104544501
Name:GRIPP, MARK
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:
Last Name:GRIPP
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:46-157 NAHIKU PL
Mailing Address - Street 2:
Mailing Address - City:KANEOHE
Mailing Address - State:HI
Mailing Address - Zip Code:96744-3625
Mailing Address - Country:US
Mailing Address - Phone:403-594-1883
Mailing Address - Fax:
Practice Address - Street 1:711 KAPIOLANI BLVD STE 200
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96813-6028
Practice Address - Country:US
Practice Address - Phone:403-594-1883
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-22
Last Update Date:2022-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTMED-PHYS-LIC-1140912085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology