Provider Demographics
NPI:1427740364
Name:GROTJOHAN, NICHOLAS DAVID
Entity type:Individual
Prefix:MR
First Name:NICHOLAS
Middle Name:DAVID
Last Name:GROTJOHAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11110 W OAKLAND PARK BLVD STE 376
Mailing Address - Street 2:
Mailing Address - City:SUNRISE
Mailing Address - State:FL
Mailing Address - Zip Code:33351-6808
Mailing Address - Country:US
Mailing Address - Phone:954-297-7369
Mailing Address - Fax:
Practice Address - Street 1:5881 NW 16TH PL APT 219
Practice Address - Street 2:
Practice Address - City:SUNRISE
Practice Address - State:FL
Practice Address - Zip Code:33313-4776
Practice Address - Country:US
Practice Address - Phone:954-297-7369
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-22
Last Update Date:2023-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLW473363171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLH1019-023Medicaid