Provider Demographics
NPI:1760541304
Name:GRUMBLES, LORETTA (MD)
Entity Type:Individual
Prefix:
First Name:LORETTA
Middle Name:
Last Name:GRUMBLES
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:PO BOX 2283
Mailing Address - Street 2:
Mailing Address - City:SUGAR LAND
Mailing Address - State:TX
Mailing Address - Zip Code:77487-2283
Mailing Address - Country:US
Mailing Address - Phone:281-773-6631
Mailing Address - Fax:713-583-1053
Practice Address - Street 1:1908 POST OFFICE ST
Practice Address - Street 2:
Practice Address - City:GALVESTON
Practice Address - State:TX
Practice Address - Zip Code:77550-2008
Practice Address - Country:US
Practice Address - Phone:409-682-3863
Practice Address - Fax:713-583-1053
Is Sole Proprietor?:No
Enumeration Date:2006-12-08
Last Update Date:2023-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL0227207RG0300X, 207RH0002X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
No207RH0002XAllopathic & Osteopathic PhysiciansInternal MedicineHospice and Palliative Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX043149603Medicaid
TX043149603Medicaid
TX8689N1Medicare PIN