Provider Demographics
NPI:1023101557
Name:GRUSHKIN, CARL MAYER (MD)
Entity type:Individual
Prefix:
First Name:CARL
Middle Name:MAYER
Last Name:GRUSHKIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6430 SUNSET BLVD.
Mailing Address - Street 2:SUITE 600
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90028-7900
Mailing Address - Country:US
Mailing Address - Phone:323-361-2337
Mailing Address - Fax:323-361-8491
Practice Address - Street 1:4650 SUNSET BLVD.
Practice Address - Street 2:MS# 40
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90027-6062
Practice Address - Country:US
Practice Address - Phone:323-361-2102
Practice Address - Fax:323-361-1829
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2008-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG138852080P0210X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0210XAllopathic & Osteopathic PhysiciansPediatricsPediatric Nephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G138850Medicaid
CA00G138850G07OtherCALOPTIMA
CAA39110Medicare UPIN
CAWG19885AMedicare ID - Type Unspecified