Provider Demographics
NPI:1447319306
Name:GRIMALDI, LISA M (MD)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:M
Last Name:GRIMALDI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3200 E CAMELBACK RD
Mailing Address - Street 2:STE 250
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85018-2327
Mailing Address - Country:US
Mailing Address - Phone:602-933-1813
Mailing Address - Fax:
Practice Address - Street 1:1919 E THOMAS RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85016
Practice Address - Country:US
Practice Address - Phone:602-933-1784
Practice Address - Fax:602-933-1785
Is Sole Proprietor?:No
Enumeration Date:2006-12-07
Last Update Date:2018-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC100123642080P0203X
NJ25MA079595002080P0203X
AZ368532080P0203X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0203XAllopathic & Osteopathic PhysiciansPediatricsPediatric Critical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0074624Medicaid
DE250387785Medicaid
NJ0074624Medicaid