Provider Demographics
NPI:1225032998
Name:GRUBER, MICHAEL DAVID (M D PC)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:DAVID
Last Name:GRUBER
Suffix:
Gender:M
Credentials:M D PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1970 E 3RD AVE
Mailing Address - Street 2:
Mailing Address - City:DURANGO
Mailing Address - State:CO
Mailing Address - Zip Code:81301-5056
Mailing Address - Country:US
Mailing Address - Phone:970-247-2214
Mailing Address - Fax:970-247-3277
Practice Address - Street 1:106 BLANCA AVE STE 300
Practice Address - Street 2:
Practice Address - City:ALAMOSA
Practice Address - State:CO
Practice Address - Zip Code:81101-2340
Practice Address - Country:US
Practice Address - Phone:719-589-3658
Practice Address - Fax:719-589-0997
Is Sole Proprietor?:No
Enumeration Date:2005-06-09
Last Update Date:2020-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM9459207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM13911Medicaid
NM13911Medicaid