Provider Demographics
NPI:1235218439
Name:GROGAN, BRIAN (MD)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:GROGAN
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 1:6153 CAMINITO DEL OESTE
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92111-6822
Mailing Address - Country:US
Mailing Address - Phone:928-446-1819
Mailing Address - Fax:928-782-7473
Practice Address - Street 1:6973 LINDA VISTA RD
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92111-6342
Practice Address - Country:US
Practice Address - Phone:858-279-0925
Practice Address - Fax:858-633-4680
Is Sole Proprietor?:No
Enumeration Date:2006-11-06
Last Update Date:2022-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ21573207V00000X
CAG63543207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ132902Medicaid
AZE93430Medicare UPIN
AZ132902Medicaid