Provider Demographics
NPI:1396874889
Name:GRONSBELL, MARK DANIEL (MD)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:DANIEL
Last Name:GRONSBELL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:3876 CLUBLAND DR
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30068-4008
Mailing Address - Country:US
Mailing Address - Phone:770-851-3611
Mailing Address - Fax:
Practice Address - Street 1:3876 CLUBLAND DR
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30068-4008
Practice Address - Country:US
Practice Address - Phone:770-851-3611
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-02
Last Update Date:2020-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0174572084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAD29626Medicare UPIN