Provider Demographics
NPI:1316936826
Name:GRILL, DAVID RICHARD (MD)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:RICHARD
Last Name:GRILL
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 1:121 S OCEAN AVE
Mailing Address - Street 2:
Mailing Address - City:FREEPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11520-4452
Mailing Address - Country:US
Mailing Address - Phone:516-379-5005
Mailing Address - Fax:516-379-9053
Practice Address - Street 1:121 S OCEAN AVE
Practice Address - Street 2:
Practice Address - City:FREEPORT
Practice Address - State:NY
Practice Address - Zip Code:11520-4452
Practice Address - Country:US
Practice Address - Phone:516-379-5005
Practice Address - Fax:516-379-9053
Is Sole Proprietor?:No
Enumeration Date:2005-10-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY149125207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00842966Medicaid
NY15 D 991Medicare ID - Type Unspecified
A52017Medicare UPIN