Provider Demographics
NPI:1245211440
Name:GRODSTEIN, GERALD (MD)
Entity Type:Individual
Prefix:
First Name:GERALD
Middle Name:
Last Name:GRODSTEIN
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 1:177 N DEAN ST
Mailing Address - Street 2:SUITE 207
Mailing Address - City:ENGLEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07631-2533
Mailing Address - Country:US
Mailing Address - Phone:201-567-0446
Mailing Address - Fax:
Practice Address - Street 1:177 N DEAN ST
Practice Address - Street 2:SUITE 207
Practice Address - City:ENGLEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07631-2533
Practice Address - Country:US
Practice Address - Phone:201-567-0446
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-07
Last Update Date:2007-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA03799200207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJBP293OtherOXFORD HEALTH
NJ412640OtherCIGNA
NJ0K3260OtherHEALTH NET
NJ412640OtherCIGNA
NJ0K3260OtherHEALTH NET
NJ524479Medicare ID - Type Unspecified