Provider Demographics
NPI:1194776344
Name:GRIMM, JUDITH BYNUM (MD)
Entity type:Individual
Prefix:DR
First Name:JUDITH
Middle Name:BYNUM
Last Name:GRIMM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:JUDITH
Other - Middle Name:BYNUM
Other - Last Name:NANCE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:464847 E 1098 RD
Mailing Address - Street 2:
Mailing Address - City:SALLISAW
Mailing Address - State:OK
Mailing Address - Zip Code:74955-5320
Mailing Address - Country:US
Mailing Address - Phone:318-794-9937
Mailing Address - Fax:
Practice Address - Street 1:4600 ROGERS AVE
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72903-3149
Practice Address - Country:US
Practice Address - Phone:479-494-7443
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2018-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD.14759R207Q00000X
ARE-9002207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA030477389OtherHUMANA
LA030477389OtherBEST CARE NETWORK
LA030477389OtherUNITED HEALTHCARE
LA1438154Medicaid
LA030477389OtherHUMANA MILITARY
LA030477389OtherHUMANA
LA030477389OtherBEST CARE NETWORK