Provider Demographics
NPI:1326051632
Name:GRODNER, HERBERT ALLEN (MD)
Entity Type:Individual
Prefix:MR
First Name:HERBERT
Middle Name:ALLEN
Last Name:GRODNER
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 1:158 WETHERLY LANE
Mailing Address - Street 2:
Mailing Address - City:WESTERVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43081
Mailing Address - Country:US
Mailing Address - Phone:614-895-0566
Mailing Address - Fax:614-895-7123
Practice Address - Street 1:158 WETHERBY LANE
Practice Address - Street 2:
Practice Address - City:WESTERVILLE
Practice Address - State:OH
Practice Address - Zip Code:43081
Practice Address - Country:US
Practice Address - Phone:614-895-0566
Practice Address - Fax:614-895-7123
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-15
Last Update Date:2010-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35030113G207R00000X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0204755Medicaid
A74265Medicare UPIN
OH0204755Medicaid