Provider Demographics
NPI:1407141625
Name:GRUBER, JONATHAN (DO)
Entity type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:
Last Name:GRUBER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:819 ISLAND CT
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92109-7710
Mailing Address - Country:US
Mailing Address - Phone:304-520-9302
Mailing Address - Fax:
Practice Address - Street 1:34800 BOB WILSON DR
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92134-1098
Practice Address - Country:US
Practice Address - Phone:619-532-6400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-15
Last Update Date:2024-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0102203227207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports MedicineGroup - Single Specialty