Provider Demographics
NPI:1104959220
Name:GRISONI, NICOLAS ENRIQUE (MD)
Entity type:Individual
Prefix:DR
First Name:NICOLAS
Middle Name:ENRIQUE
Last Name:GRISONI
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:PO BOX 80217
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85060-0217
Mailing Address - Country:US
Mailing Address - Phone:602-385-2115
Mailing Address - Fax:602-772-3801
Practice Address - Street 1:9327 N 3RD ST STE 300
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85020-2476
Practice Address - Country:US
Practice Address - Phone:602-648-5444
Practice Address - Fax:602-772-3801
Is Sole Proprietor?:No
Enumeration Date:2007-03-14
Last Update Date:2024-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ72936207X00000X, 207XS0117X
OH35-092688207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the Spine
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH3030900Medicaid
OH4285791Medicare PIN