Provider Demographics
NPI:1871598011
Name:GRISHAM, JEFFREY WILLIAM (MD)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:WILLIAM
Last Name:GRISHAM
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 1:3615 SE KENTUCKY ST
Mailing Address - Street 2:
Mailing Address - City:BARTLESVILLE
Mailing Address - State:OK
Mailing Address - Zip Code:74006-2324
Mailing Address - Country:US
Mailing Address - Phone:918-333-2020
Mailing Address - Fax:918-335-3253
Practice Address - Street 1:3615 SE KENTUCKY ST
Practice Address - Street 2:
Practice Address - City:BARTLESVILLE
Practice Address - State:OK
Practice Address - Zip Code:74006-2324
Practice Address - Country:US
Practice Address - Phone:918-333-2020
Practice Address - Fax:918-335-3253
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-15
Last Update Date:2016-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK15291207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100102110AMedicaid
OK100102110AMedicaid