Provider Demographics
NPI:1255373304
Name:DELLA GROTTA, GARY T (MD)
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:T
Last Name:DELLA GROTTA
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 1:43B BIRCH STREET
Mailing Address - Street 2:
Mailing Address - City:DERRY
Mailing Address - State:NH
Mailing Address - Zip Code:03038
Mailing Address - Country:US
Mailing Address - Phone:603-434-0327
Mailing Address - Fax:603-437-7175
Practice Address - Street 1:43B BIRCH STREET
Practice Address - Street 2:
Practice Address - City:DERRY
Practice Address - State:NH
Practice Address - Zip Code:03038
Practice Address - Country:US
Practice Address - Phone:603-434-0327
Practice Address - Fax:603-437-7175
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH7298208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH30001472Medicaid