Provider Demographics
NPI:1316148646
Name:GRZYWACZ, ROBERT B (DPM)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:B
Last Name:GRZYWACZ
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3221 E WARM SPRINGS RD
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89120-3157
Mailing Address - Country:US
Mailing Address - Phone:702-733-7617
Mailing Address - Fax:702-733-1732
Practice Address - Street 1:3221 E WARM SPRINGS RD
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89120-3157
Practice Address - Country:US
Practice Address - Phone:702-733-7617
Practice Address - Fax:702-733-1732
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-31
Last Update Date:2008-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV793965375213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV5623276299OtherTIN
NVP00058662OtherRAILROAD MEDICARE
NV5623276299OtherTIN
NVT67226Medicare UPIN
NVV37962Medicare ID - Type UnspecifiedGROUP NUMBER