Provider Demographics
NPI:1023087517
Name:GRUCHALLA, REBECCA SUE (MD PHD)
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:SUE
Last Name:GRUCHALLA
Suffix:
Gender:F
Credentials:MD PHD
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 845347
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-5347
Mailing Address - Country:US
Mailing Address - Phone:214-645-2866
Mailing Address - Fax:214-648-9102
Practice Address - Street 1:5323 HARRY HINES BLVD
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75390-7208
Practice Address - Country:US
Practice Address - Phone:214-645-2866
Practice Address - Fax:214-648-9102
Is Sole Proprietor?:No
Enumeration Date:2006-03-16
Last Update Date:2008-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH5240207RA0201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RA0201XAllopathic & Osteopathic PhysiciansInternal MedicineAllergy & Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
D87445Medicare UPIN
TX82G237Medicare ID - Type Unspecified