Provider Demographics
NPI:1659328516
Name:GRUBE, THOMAS J (MD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:J
Last Name:GRUBE
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 1:1514 BUCCANEER PL
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58504-8982
Mailing Address - Country:US
Mailing Address - Phone:701-250-6820
Mailing Address - Fax:
Practice Address - Street 1:107 3RD AVE NW
Practice Address - Street 2:
Practice Address - City:MANDAN
Practice Address - State:ND
Practice Address - Zip Code:58554-3129
Practice Address - Country:US
Practice Address - Phone:701-751-2131
Practice Address - Fax:701-751-2133
Is Sole Proprietor?:No
Enumeration Date:2006-05-27
Last Update Date:2010-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND9201207W00000X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND12035Medicaid
ND12035Medicaid