Provider Demographics
NPI:1477649531
Name:GRUDEM, JON MARK (MD)
Entity Type:Individual
Prefix:DR
First Name:JON
Middle Name:MARK
Last Name:GRUDEM
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 1:575 N SIOUX POINT RD
Mailing Address - Street 2:
Mailing Address - City:NORTH SIOUX CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57049-5312
Mailing Address - Country:US
Mailing Address - Phone:605-217-2667
Mailing Address - Fax:605-217-2900
Practice Address - Street 1:575 N SIOUX POINT RD
Practice Address - Street 2:
Practice Address - City:NORTH SIOUX CITY
Practice Address - State:SD
Practice Address - Zip Code:57049-5312
Practice Address - Country:US
Practice Address - Phone:605-217-2667
Practice Address - Fax:605-217-2900
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2011-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD73542084N0400X
IA385762084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1295480002Medicare NSC
SD1295480001Medicare NSC
IA479350017Medicare PIN
SD103361Medicare PIN