Provider Demographics
NPI:1154616001
Name:GRUNWALD, DOUGLAS J (MD)
Entity type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:J
Last Name:GRUNWALD
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 1:2200 WHITNEY AVE STE 360
Mailing Address - Street 2:
Mailing Address - City:HAMDEN
Mailing Address - State:CT
Mailing Address - Zip Code:06518-3602
Mailing Address - Country:US
Mailing Address - Phone:203-281-4463
Mailing Address - Fax:203-287-2930
Practice Address - Street 1:2200 WHITNEY AVE STE 360
Practice Address - Street 2:
Practice Address - City:HAMDEN
Practice Address - State:CT
Practice Address - Zip Code:06518-3602
Practice Address - Country:US
Practice Address - Phone:203-281-4463
Practice Address - Fax:203-287-2930
Is Sole Proprietor?:No
Enumeration Date:2011-06-17
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT56120207RG0100X
MA248457390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1154616001Medicaid