Provider Demographics
NPI:1518961952
Name:GRUENWALD, CHARLES JR (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:
Last Name:GRUENWALD
Suffix:JR
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 1:4309 BLUEBONNET BLVD
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70809
Mailing Address - Country:US
Mailing Address - Phone:225-925-3140
Mailing Address - Fax:225-223-6010
Practice Address - Street 1:4309 BLUEBONNET BLVD
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70809
Practice Address - Country:US
Practice Address - Phone:225-925-3140
Practice Address - Fax:225-223-6010
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-13
Last Update Date:2011-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA04294R208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA13-00043OtherUNITED
LA690256OtherAETNA
LA1188506Medicaid
LA690256OtherAETNA
LA52870Medicare ID - Type Unspecified