Provider Demographics
NPI:1194708479
Name:GROSSBLAT, DAVID A (MD, PT)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:A
Last Name:GROSSBLAT
Suffix:
Gender:M
Credentials:MD, PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 W CLARENDON AVE
Mailing Address - Street 2:SUITE 142
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85013-3420
Mailing Address - Country:US
Mailing Address - Phone:602-234-1803
Mailing Address - Fax:602-234-3748
Practice Address - Street 1:350 W THOMAS RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85013-4409
Practice Address - Country:US
Practice Address - Phone:602-406-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-21
Last Update Date:2014-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5561225100000X
AZ44436207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ650026148OtherRAILROAD MEDICARE
AZ747313Medicaid
AZ86080015085259C305OtherTRIWEST
AZ747313Medicaid
AZZ72758Medicare PIN
P80093Medicare UPIN