Provider Demographics
NPI:1437682267
Name:GRUNDT, BRIAN JEFFREY (DO)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:JEFFREY
Last Name:GRUNDT
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:180 JOHN F KENNEDY DR
Mailing Address - Street 2:
Mailing Address - City:ATLANTIS
Mailing Address - State:FL
Mailing Address - Zip Code:33462-6641
Mailing Address - Country:US
Mailing Address - Phone:561-967-6500
Mailing Address - Fax:
Practice Address - Street 1:180 JOHN F KENNEDY DR
Practice Address - Street 2:
Practice Address - City:ATLANTIS
Practice Address - State:FL
Practice Address - Zip Code:33462-6641
Practice Address - Country:US
Practice Address - Phone:561-967-6500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-08
Last Update Date:2024-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS16891207R00000X, 208M00000X, 207RS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RS0010XAllopathic & Osteopathic PhysiciansInternal MedicineSports Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL108480300Medicaid