Provider Demographics
NPI:1285602151
Name:GRUDZINSKI, ANDREW ROBERT (MD)
Entity type:Individual
Prefix:
First Name:ANDREW
Middle Name:ROBERT
Last Name:GRUDZINSKI
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 1:7150 W SUNSET RD STE 201A
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89113-1981
Mailing Address - Country:US
Mailing Address - Phone:702-902-1939
Mailing Address - Fax:702-442-1886
Practice Address - Street 1:7500 SMOKE RANCH RD STE 200
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89128-0373
Practice Address - Country:US
Practice Address - Phone:702-233-0727
Practice Address - Fax:702-233-4799
Is Sole Proprietor?:No
Enumeration Date:2006-03-08
Last Update Date:2021-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC21055208800000X
NV20748208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC000000206911OtherUNISON HEALTH PLAN
SC5580793OtherAETNA
SCP00360558OtherRAILROAD MEDICARE
SC771828OtherWELLCARE
SC80023030OtherSELECT HEALTH
SCGP4522Medicaid
SCT50860Medicaid
NC790598LOtherEDS
SC8522204OtherCIGNA
SCGP1521Medicaid
NC2280313OtherCIGNA MEDICARE
NC5907458Medicaid
NC5907458Medicaid
SCGP4522Medicaid
SCG892778568Medicare PIN