Provider Demographics
NPI:1336144914
Name:GRUNWALD, MARK A (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:A
Last Name:GRUNWALD
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 1:304 S JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:PRAIRIE DU CHIEN
Mailing Address - State:WI
Mailing Address - Zip Code:53821-1821
Mailing Address - Country:US
Mailing Address - Phone:608-326-5459
Mailing Address - Fax:
Practice Address - Street 1:304 S JACKSON ST
Practice Address - Street 2:
Practice Address - City:PRAIRIE DU CHIEN
Practice Address - State:WI
Practice Address - Zip Code:53821-1821
Practice Address - Country:US
Practice Address - Phone:608-326-5459
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-20
Last Update Date:2008-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI23439207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI30483400Medicaid
WI30483400Medicaid