Provider Demographics
NPI:1427317155
Name:CONNERY, GRISSIM CLARK (DO, RD)
Entity type:Individual
Prefix:MR
First Name:GRISSIM
Middle Name:CLARK
Last Name:CONNERY
Suffix:
Gender:M
Credentials:DO, RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3016 W CHARLESTON BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89102-1973
Mailing Address - Country:US
Mailing Address - Phone:702-780-2315
Mailing Address - Fax:702-895-4014
Practice Address - Street 1:1707 W CHARLESTON BLVD STE 100
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89102-2352
Practice Address - Country:US
Practice Address - Phone:702-676-3650
Practice Address - Fax:702-671-5198
Is Sole Proprietor?:No
Enumeration Date:2012-05-15
Last Update Date:2024-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1086129133V00000X
NVDO3640207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No133V00000XDietary & Nutritional Service ProvidersDietitian, Registered