Provider Demographics
NPI:1528419199
Name:AGRUSA, ANTHONY JOSEPH (DO)
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:JOSEPH
Last Name:AGRUSA
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5701 BOW POINTE DR STE 100
Mailing Address - Street 2:
Mailing Address - City:CLARKSTON
Mailing Address - State:MI
Mailing Address - Zip Code:48346-3199
Mailing Address - Country:US
Mailing Address - Phone:248-625-2621
Mailing Address - Fax:248-625-2622
Practice Address - Street 1:5701 BOW POINTE DR STE 100
Practice Address - Street 2:
Practice Address - City:CLARKSTON
Practice Address - State:MI
Practice Address - Zip Code:48346
Practice Address - Country:US
Practice Address - Phone:248-625-2621
Practice Address - Fax:248-625-2622
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-24
Last Update Date:2019-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101022413207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5101022413OtherMEDICAL LICENSE NUMBER