Provider Demographics
NPI:1124011085
Name:GRUNDFAST, MATTHEW B (DO)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:B
Last Name:GRUNDFAST
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:130 E WESTERLEE DR
Mailing Address - Street 2:
Mailing Address - City:LEESBURG
Mailing Address - State:GA
Mailing Address - Zip Code:31763-5817
Mailing Address - Country:US
Mailing Address - Phone:229-886-5150
Mailing Address - Fax:682-200-2084
Practice Address - Street 1:111 FAIRVIEW PARK DR
Practice Address - Street 2:
Practice Address - City:DUBLIN
Practice Address - State:GA
Practice Address - Zip Code:31021-2501
Practice Address - Country:US
Practice Address - Phone:478-277-1929
Practice Address - Fax:478-304-1468
Is Sole Proprietor?:No
Enumeration Date:2005-08-25
Last Update Date:2022-05-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA052944207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAH85670Medicare UPIN
GA511G701098Medicare Oscar/Certification