Provider Demographics
NPI:1407904634
Name:GRUDEN, GREGORY JOHN (OD)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:JOHN
Last Name:GRUDEN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1720 NORTHWOOD BLVD
Mailing Address - Street 2:
Mailing Address - City:ROYAL OAK
Mailing Address - State:MI
Mailing Address - Zip Code:48073-3805
Mailing Address - Country:US
Mailing Address - Phone:248-548-6605
Mailing Address - Fax:
Practice Address - Street 1:2800 W BIG BEAVER RD
Practice Address - Street 2:STE. N-104
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48084-3206
Practice Address - Country:US
Practice Address - Phone:248-649-6766
Practice Address - Fax:248-649-9513
Is Sole Proprietor?:No
Enumeration Date:2007-01-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901003571152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIU33239Medicare UPIN