Provider Demographics
NPI:1477766871
Name:GROHMAN, MICHAEL ROBERT (IDC)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:ROBERT
Last Name:GROHMAN
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 555341
Mailing Address - Street 2:
Mailing Address - City:CAMP PENDLETON
Mailing Address - State:CA
Mailing Address - Zip Code:92055-5341
Mailing Address - Country:US
Mailing Address - Phone:760-725-5250
Mailing Address - Fax:760-725-5298
Practice Address - Street 1:41256 STEWART MESA RD
Practice Address - Street 2:
Practice Address - City:CAMP PENDLETON
Practice Address - State:CA
Practice Address - Zip Code:92055-5341
Practice Address - Country:US
Practice Address - Phone:760-725-5250
Practice Address - Fax:760-725-5298
Is Sole Proprietor?:No
Enumeration Date:2007-05-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman