Provider Demographics
NPI:1194775932
Name:GRUNDY, JOHN PATRICK III (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:PATRICK
Last Name:GRUNDY
Suffix:III
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 1:615 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MD
Mailing Address - Zip Code:20707-4065
Mailing Address - Country:US
Mailing Address - Phone:301-725-3010
Mailing Address - Fax:301-725-3271
Practice Address - Street 1:615 MAIN ST
Practice Address - Street 2:
Practice Address - City:LAUREL
Practice Address - State:MD
Practice Address - Zip Code:20707-4065
Practice Address - Country:US
Practice Address - Phone:301-725-3010
Practice Address - Fax:301-725-3271
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-11
Last Update Date:2015-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0052388207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC91930002OtherCAREFIRST DC
MD407806300Medicaid
000C02E53Medicare ID - Type Unspecified
MD407806300Medicaid
DC000C02E53Medicare PIN