Provider Demographics
NPI:1316949944
Name:GRISONI, ENRIQUE R (MD)
Entity type:Individual
Prefix:DR
First Name:ENRIQUE
Middle Name:R
Last Name:GRISONI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 743409
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-3409
Mailing Address - Country:US
Mailing Address - Phone:727-532-0002
Mailing Address - Fax:727-532-1325
Practice Address - Street 1:10141 BIG BEND RD
Practice Address - Street 2:103
Practice Address - City:RIVERVIEW
Practice Address - State:FL
Practice Address - Zip Code:33578-7419
Practice Address - Country:US
Practice Address - Phone:813-397-1274
Practice Address - Fax:813-397-1271
Is Sole Proprietor?:No
Enumeration Date:2005-08-12
Last Update Date:2016-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME2086S0120X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0120XAllopathic & Osteopathic PhysiciansSurgeryPediatric Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZAZ0884680OtherBC/BS
AZ564642-01Medicaid
FL002583200Medicaid
F13551Medicare UPIN
AZAZ0884680OtherBC/BS