Provider Demographics
NPI:1659356145
Name:GRABB, BRENDA (MD)
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:
Last Name:GRABB
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1011 N WEBER ST
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80903-2466
Mailing Address - Country:US
Mailing Address - Phone:719-578-1162
Mailing Address - Fax:719-578-1462
Practice Address - Street 1:1400 E BOULDER ST
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80909-5533
Practice Address - Country:US
Practice Address - Phone:719-365-5120
Practice Address - Fax:719-365-6860
Is Sole Proprietor?:No
Enumeration Date:2005-12-07
Last Update Date:2012-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO428342085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO05505011Medicaid
COH09610Medicare UPIN
CO538488Medicare PIN