Provider Demographics
NPI:1477565026
Name:GROMKO, WILLIAM ANTHONY (MD)
Entity Type:Individual
Prefix:MR
First Name:WILLIAM
Middle Name:ANTHONY
Last Name:GROMKO
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 1:17055 RUBEN LN
Mailing Address - Street 2:
Mailing Address - City:SANDY
Mailing Address - State:OR
Mailing Address - Zip Code:97055-9276
Mailing Address - Country:US
Mailing Address - Phone:503-668-8002
Mailing Address - Fax:
Practice Address - Street 1:17055 RUBEN LN
Practice Address - Street 2:
Practice Address - City:SANDY
Practice Address - State:OR
Practice Address - Zip Code:97055-9276
Practice Address - Country:US
Practice Address - Phone:503-668-8002
Practice Address - Fax:503-668-5246
Is Sole Proprietor?:No
Enumeration Date:2006-08-12
Last Update Date:2021-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA14461207Q00000X
MN66750207Q00000X
ORMD204079207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA147208OtherWORKERS COMPENSATION
WA7280GROtherBLUE CROSS BLUE SHIELD
WA1112713Medicaid
WA080168652OtherPALMETTO GBA
WA610278200OtherU.S. DEPT. OF LABOR
WA912107280985030000OtherTRICARE
WA1112713Medicaid
WAGAB20307Medicare PIN