Provider Demographics
NPI:1992808398
Name:GROSDIDIER, JONATHAN L (MD)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:L
Last Name:GROSDIDIER
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 1:111 S 5TH ST
Mailing Address - Street 2:
Mailing Address - City:DOUGLAS
Mailing Address - State:WY
Mailing Address - Zip Code:82633-2434
Mailing Address - Country:US
Mailing Address - Phone:307-358-2122
Mailing Address - Fax:307-358-9216
Practice Address - Street 1:111 S 5TH ST
Practice Address - Street 2:
Practice Address - City:DOUGLAS
Practice Address - State:WY
Practice Address - Zip Code:82633-2434
Practice Address - Country:US
Practice Address - Phone:307-358-2122
Practice Address - Fax:307-358-9216
Is Sole Proprietor?:No
Enumeration Date:2006-09-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY7331A208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY314089OtherBCBS OF WYOMING
WYF85514Medicare UPIN
WYW20720Medicare ID - Type Unspecified