Provider Demographics
NPI:1366979007
Name:GRILLIOT, JORDAN (DO)
Entity type:Individual
Prefix:DR
First Name:JORDAN
Middle Name:
Last Name:GRILLIOT
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2211 NORTHBRIDGE TRL
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:OH
Mailing Address - Zip Code:45373-4667
Mailing Address - Country:US
Mailing Address - Phone:937-626-3110
Mailing Address - Fax:
Practice Address - Street 1:3130 N COUNTY ROAD 25A STE 116
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:OH
Practice Address - Zip Code:45373-1337
Practice Address - Country:US
Practice Address - Phone:937-335-3561
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-12
Last Update Date:2025-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA330890207XX0005X
390200000X
OH34.016569207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0230339Medicaid
OH34.016569OtherOH LICENSE