Provider Demographics
NPI:1275575276
Name:GRODEN, DAVID L (MD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:L
Last Name:GRODEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:16650 W BLUEMOUND RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53005-5920
Mailing Address - Country:US
Mailing Address - Phone:262-827-9200
Mailing Address - Fax:262-827-9858
Practice Address - Street 1:16650 W BLUEMOUND RD
Practice Address - Street 2:SUITE 200
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53005-5920
Practice Address - Country:US
Practice Address - Phone:262-827-9200
Practice Address - Fax:262-827-9858
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2015-09-15
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WI31054207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI31605700Medicaid
WI31605700Medicaid
WI685900015Medicare PIN
WI013630016Medicare PIN