Provider Demographics
NPI:1518960921
Name:GROSSNICKLE, BRUCE P (MD)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:P
Last Name:GROSSNICKLE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2251 DUBOIS DR
Mailing Address - Street 2:
Mailing Address - City:WARSAW
Mailing Address - State:IN
Mailing Address - Zip Code:46580-3212
Mailing Address - Country:US
Mailing Address - Phone:574-269-2777
Mailing Address - Fax:574-371-4697
Practice Address - Street 1:2251 DUBOIS DR
Practice Address - Street 2:
Practice Address - City:WARSAW
Practice Address - State:IN
Practice Address - Zip Code:46580-3212
Practice Address - Country:US
Practice Address - Phone:574-269-2777
Practice Address - Fax:574-371-4697
Is Sole Proprietor?:No
Enumeration Date:2005-05-31
Last Update Date:2016-05-05
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IN01031752A207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100324570Medicaid
IN451600AMedicare PIN
IN100324570Medicaid