Provider Demographics
NPI:1497709125
Name:GRGUREVIC, MIROSLAV (MD)
Entity Type:Individual
Prefix:MR
First Name:MIROSLAV
Middle Name:
Last Name:GRGUREVIC
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:PO BOX 7096
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95267
Mailing Address - Country:US
Mailing Address - Phone:209-956-7725
Mailing Address - Fax:209-956-7733
Practice Address - Street 1:825 DELBON AVE
Practice Address - Street 2:
Practice Address - City:TURLOCK
Practice Address - State:CA
Practice Address - Zip Code:95382
Practice Address - Country:US
Practice Address - Phone:209-667-4200
Practice Address - Fax:209-669-2377
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-19
Last Update Date:2012-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA40300207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A403000Medicaid
CAP00787019Medicare PIN
CA00A403001Medicare PIN
G00613Medicare UPIN
CA00A403000Medicaid
CA00A403002Medicare PIN