Provider Demographics
NPI:1477039667
Name:GRUBSTAD, FREDERICK II
Entity Type:Individual
Prefix:MR
First Name:FREDERICK
Middle Name:
Last Name:GRUBSTAD
Suffix:II
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14360 RIOS CANYON RD SPC 76
Mailing Address - Street 2:
Mailing Address - City:EL CAJON
Mailing Address - State:CA
Mailing Address - Zip Code:92021-2735
Mailing Address - Country:US
Mailing Address - Phone:619-249-3746
Mailing Address - Fax:
Practice Address - Street 1:1777 BUCKMAN SPRINGS RD
Practice Address - Street 2:
Practice Address - City:CAMPO
Practice Address - State:CA
Practice Address - Zip Code:91906-2022
Practice Address - Country:US
Practice Address - Phone:619-478-5696
Practice Address - Fax:619-478-2404
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-11
Last Update Date:2022-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95019498363LP0808X
CA535781163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163W00000XNursing Service ProvidersRegistered NurseGroup - Multi-Specialty
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty