Provider Demographics
NPI:1134159288
Name:GRUA, JAMES RUSSELL (MD)
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:RUSSELL
Last Name:GRUA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:JAMES
Other - Middle Name:R
Other - Last Name:GRUA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:7181 S CAMPUS VIEW DR STE 200
Mailing Address - Street 2:
Mailing Address - City:WEST JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84084-4312
Mailing Address - Country:US
Mailing Address - Phone:801-965-3600
Mailing Address - Fax:
Practice Address - Street 1:2965 W 3500 S
Practice Address - Street 2:
Practice Address - City:WEST VALLEY CITY
Practice Address - State:UT
Practice Address - Zip Code:84119-3602
Practice Address - Country:US
Practice Address - Phone:801-965-3600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-04
Last Update Date:2023-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT180796-1205207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTE90585Medicare UPIN
UT005545614Medicare PIN
UT000063282Medicare PIN
E90585Medicare UPIN