Provider Demographics
NPI:1730153966
Name:GRODIN, JERROLD (MD)
Entity type:Individual
Prefix:
First Name:JERROLD
Middle Name:
Last Name:GRODIN
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:PO BOX 660080
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75266-0080
Mailing Address - Country:US
Mailing Address - Phone:214-237-6636
Mailing Address - Fax:
Practice Address - Street 1:621 N HALL ST
Practice Address - Street 2:SUITE 400
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75226-1339
Practice Address - Country:US
Practice Address - Phone:214-826-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-14
Last Update Date:2016-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG1023207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX456878YL7AMedicare PIN
TX456878YL7BMedicare PIN
TX456878YNGSMedicare PIN