Provider Demographics
NPI:1629000534
Name:GROTH, DAVID WILLIAM (MD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:WILLIAM
Last Name:GROTH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:6425 NICOLLET AVE
Mailing Address - Street 2:SUITE # 202
Mailing Address - City:RICHFIELD
Mailing Address - State:MN
Mailing Address - Zip Code:55423-1675
Mailing Address - Country:US
Mailing Address - Phone:612-869-2086
Mailing Address - Fax:612-869-4903
Practice Address - Street 1:6425 NICOLLET AVE
Practice Address - Street 2:SUITE # 202
Practice Address - City:RICHFIELD
Practice Address - State:MN
Practice Address - Zip Code:55423-1675
Practice Address - Country:US
Practice Address - Phone:612-869-2086
Practice Address - Fax:612-869-4903
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2012-07-23
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MN29749207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN0492002OtherPREFERRED ONE
MN722390100Medicaid
MN09Q99GROtherBCBS
MN03-00033OtherMEDICA CHOICE & PRIMARY
MN100187OtherUCARE
MNHP13424OtherHEALTHPARTNERS
MN20931OtherARAZ
MN20931OtherARAZ
MN03-00033OtherMEDICA CHOICE & PRIMARY