Provider Demographics
NPI:1114346566
Name:GRUBE, JORDON GUY (DO)
Entity Type:Individual
Prefix:DR
First Name:JORDON
Middle Name:GUY
Last Name:GRUBE
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 1:30 STARBUCK DR UNIT 208
Mailing Address - Street 2:
Mailing Address - City:GREEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:12183-1264
Mailing Address - Country:US
Mailing Address - Phone:484-223-9635
Mailing Address - Fax:
Practice Address - Street 1:50 NEW SCOTLAND AVE # MC-41
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12208-3403
Practice Address - Country:US
Practice Address - Phone:518-262-5575
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-14
Last Update Date:2022-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY306555207YX0905X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YX0905XAllopathic & Osteopathic PhysiciansOtolaryngologyOtolaryngology/Facial Plastic Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program