Provider Demographics
NPI:1184629958
Name:GRONSTEDT, JOY S (DO)
Entity Type:Individual
Prefix:
First Name:JOY
Middle Name:S
Last Name:GRONSTEDT
Suffix:
Gender:F
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:PO BOX 1547
Mailing Address - Street 2:
Mailing Address - City:SEDALIA
Mailing Address - State:MO
Mailing Address - Zip Code:65302-1547
Mailing Address - Country:US
Mailing Address - Phone:660-826-5960
Mailing Address - Fax:660-826-4852
Practice Address - Street 1:700 S HANCOCK AVE
Practice Address - Street 2:
Practice Address - City:SEDALIA
Practice Address - State:MO
Practice Address - Zip Code:65301-4638
Practice Address - Country:US
Practice Address - Phone:660-827-4664
Practice Address - Fax:660-827-4591
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-16
Last Update Date:2016-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR8F93207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO242288140Medicaid
MO0004625Medicare PIN
MO242288140Medicaid