Provider Demographics
NPI:1902184146
Name:GRUCZ, DOUGLAS ROBERT (MD)
Entity Type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:ROBERT
Last Name:GRUCZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:5952 CENTRALIA ST
Mailing Address - Street 2:
Mailing Address - City:DEARBORN HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48127-2933
Mailing Address - Country:US
Mailing Address - Phone:313-300-2783
Mailing Address - Fax:
Practice Address - Street 1:7330 N CANTON CENTER RD
Practice Address - Street 2:SUITE 111
Practice Address - City:CANTON
Practice Address - State:MI
Practice Address - Zip Code:48187-1538
Practice Address - Country:US
Practice Address - Phone:734-454-8001
Practice Address - Fax:734-454-8030
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-21
Last Update Date:2014-06-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4301099539207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4301099539OtherLICENSE