Provider Demographics
NPI:1871653758
Name:GRONG, LARRY JAY (DO)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:JAY
Last Name:GRONG
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1282 WALNUT ST
Mailing Address - Street 2:
Mailing Address - City:DAWSON
Mailing Address - State:MN
Mailing Address - Zip Code:56232-2333
Mailing Address - Country:US
Mailing Address - Phone:320-769-7393
Mailing Address - Fax:320-769-2972
Practice Address - Street 1:1282 WALNUT ST
Practice Address - Street 2:
Practice Address - City:DAWSON
Practice Address - State:MN
Practice Address - Zip Code:56232
Practice Address - Country:US
Practice Address - Phone:320-769-7393
Practice Address - Fax:320-769-2972
Is Sole Proprietor?:No
Enumeration Date:2006-12-11
Last Update Date:2022-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN39995207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN4150236-00Medicaid