Provider Demographics
NPI:1295014561
Name:GROTEKE, WALTER MATTHEW
Entity Type:Individual
Prefix:MR
First Name:WALTER
Middle Name:MATTHEW
Last Name:GROTEKE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1102 S BAYSHORE BLVD
Mailing Address - Street 2:
Mailing Address - City:SAFETY HARBOR
Mailing Address - State:FL
Mailing Address - Zip Code:34695-4258
Mailing Address - Country:US
Mailing Address - Phone:727-488-5040
Mailing Address - Fax:
Practice Address - Street 1:1102 S BAYSHORE BLVD
Practice Address - Street 2:
Practice Address - City:SAFETY HARBOR
Practice Address - State:FL
Practice Address - Zip Code:34695-4258
Practice Address - Country:US
Practice Address - Phone:727-488-5040
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-04
Last Update Date:2011-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor