Basic Information
| Provider Information | |||||||||
| NPI: | 1568435915 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GRIFFEN | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | T | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2125 CRYSTAL GROVE DR | ||||||||
| Address2: | |||||||||
| City: | LAKELAND | ||||||||
| State: | FL | ||||||||
| PostalCode: | 338016875 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8636882334 | ||||||||
| FaxNumber: | 8635770301 | ||||||||
| Practice Location | |||||||||
| Address1: | 2125 CRYSTAL GROVE DR | ||||||||
| Address2: | |||||||||
| City: | LAKELAND | ||||||||
| State: | FL | ||||||||
| PostalCode: | 338016875 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8636882334 | ||||||||
| FaxNumber: | 8635770301 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/08/2006 | ||||||||
| LastUpdateDate: | 05/28/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085N0700X | ME81316 | FL | Y | Allopathic & Osteopathic Physicians | Radiology | Neuroradiology | 2085R0202X | ME81316 | FL | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 265088600 | 05 | FL | MEDICAID |