Provider Demographics
NPI:1659366219
Name:GRULLON-MEJIA, JEANETTE (MD)
Entity Type:Individual
Prefix:
First Name:JEANETTE
Middle Name:
Last Name:GRULLON-MEJIA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JEANETTE
Other - Middle Name:A
Other - Last Name:GRULLON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:J STREET
Mailing Address - Street 2:BUILDING 3000
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76127
Mailing Address - Country:US
Mailing Address - Phone:817-782-4352
Mailing Address - Fax:
Practice Address - Street 1:J STREET
Practice Address - Street 2:BUILDING 3000
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76127
Practice Address - Country:US
Practice Address - Phone:817-782-4352
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-20
Last Update Date:2012-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN2097207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine