Provider Demographics
NPI:1730281684
Name:GRENDAHL, ROBIN (MD)
Entity Type:Individual
Prefix:
First Name:ROBIN
Middle Name:
Last Name:GRENDAHL
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 1:3500 LATOUCHE ST
Mailing Address - Street 2:SUITE 280
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99508-4209
Mailing Address - Country:US
Mailing Address - Phone:907-561-1917
Mailing Address - Fax:907-563-5373
Practice Address - Street 1:3500 LATOUCHE ST
Practice Address - Street 2:SUITE 280
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99508-4209
Practice Address - Country:US
Practice Address - Phone:907-561-1917
Practice Address - Fax:907-563-5373
Is Sole Proprietor?:No
Enumeration Date:2006-09-02
Last Update Date:2011-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AKMD3686207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKMD3686Medicaid
AKKOOWFBMCCMedicare ID - Type Unspecified
AKMD3686Medicaid