Provider Demographics
NPI:1124066980
Name:GRIM, STEPHANIE C (MD)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:C
Last Name:GRIM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:C
Other - Last Name:CARLETON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1122 NE 13TH ST
Mailing Address - Street 2:ORI 236
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73117-1039
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1200 EVERETT DR
Practice Address - Street 2:7TH FLOOR NORTH PAVILION
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73104-5047
Practice Address - Country:US
Practice Address - Phone:405-271-5215
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-03
Last Update Date:2008-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK23471208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
246627001Medicare PIN