Provider Demographics
NPI:1639127715
Name:GRONBERG, MICHAEL (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:
Last Name:GRONBERG
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 1:12461 TIMBERLAND BLVD
Mailing Address - Street 2:SUITE 309
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76244-5213
Mailing Address - Country:US
Mailing Address - Phone:817-741-5437
Mailing Address - Fax:888-400-5412
Practice Address - Street 1:9445 N BEACH ST
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76244-9059
Practice Address - Country:US
Practice Address - Phone:817-741-5437
Practice Address - Fax:888-400-5412
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2022-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036094205208000000X
TXQ0449208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL962341Medicare PIN