Basic Information
| Provider Information | |||||||||
| NPI: | 1902833742 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GRIMALDOS | ||||||||
| FirstName: | JUAN | ||||||||
| MiddleName: | PABLO | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 99371 | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761990371 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6828851855 | ||||||||
| FaxNumber: | 6828857347 | ||||||||
| Practice Location | |||||||||
| Address1: | 801 7TH AVE | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761042733 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6828854054 | ||||||||
| FaxNumber: | 6828857497 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/27/2006 | ||||||||
| LastUpdateDate: | 04/04/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | ME85392 | FL | N | Allopathic & Osteopathic Physicians | Anesthesiology | 207L00000X | L4406 | TX | N | Allopathic & Osteopathic Physicians | Anesthesiology | 207LP3000X | L4406 | TX | Y | Allopathic & Osteopathic Physicians | Anesthesiology | Pediatric Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 152965306 | 01 | TX | CSHCN | OTHER | 271316100 | 05 | FL | MEDICAID | 152965304 | 01 | TX | CSHCN | OTHER | 152965305 | 05 | TX | MEDICAID | 137345809 | 01 | TX | MEDICAID GROUP NUMBER | OTHER | 140442853 | 01 | TX | CSHCN GROUP NUMBER | OTHER |