Provider Demographics
NPI:1336170182
Name:GRITSUS, VADIM (MD)
Entity Type:Individual
Prefix:DR
First Name:VADIM
Middle Name:
Last Name:GRITSUS
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 1:7 INDUSTRIAL RD
Mailing Address - Street 2:SUITE 203
Mailing Address - City:PEQUANNOCK
Mailing Address - State:NJ
Mailing Address - Zip Code:07440-1922
Mailing Address - Country:US
Mailing Address - Phone:973-696-9050
Mailing Address - Fax:973-696-9055
Practice Address - Street 1:7 INDUSTRIAL RD
Practice Address - Street 2:SUITE 203
Practice Address - City:PEQUANNOCK
Practice Address - State:NJ
Practice Address - Zip Code:07440-1922
Practice Address - Country:US
Practice Address - Phone:973-696-9050
Practice Address - Fax:973-696-9055
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-06
Last Update Date:2008-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA07576600174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ074233R6RMedicare ID - Type Unspecified
NJH97459Medicare UPIN