Provider Demographics
NPI:1417911827
Name:GRUNDBERG, JULIE ANN (DPM)
Entity Type:Individual
Prefix:DR
First Name:JULIE
Middle Name:ANN
Last Name:GRUNDBERG
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:DR
Other - First Name:JULIE
Other - Middle Name:
Other - Last Name:PENDARVIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPM
Mailing Address - Street 1:6001 WESTOWN PARKWAY
Mailing Address - Street 2:
Mailing Address - City:WEST DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50266-7702
Mailing Address - Country:US
Mailing Address - Phone:515-224-1414
Mailing Address - Fax:515-224-5140
Practice Address - Street 1:6001 WESTOWN PKWY
Practice Address - Street 2:
Practice Address - City:WEST DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50266-7719
Practice Address - Country:US
Practice Address - Phone:515-224-1414
Practice Address - Fax:515-224-5140
Is Sole Proprietor?:No
Enumeration Date:2006-04-13
Last Update Date:2022-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA00665213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1193136Medicaid
U76716Medicare UPIN
IAI0780Medicare ID - Type Unspecified