Provider Demographics
NPI:1477543080
Name:GROTTKAU, BRIAN EDWARD (MD)
Entity type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:EDWARD
Last Name:GROTTKAU
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 1:1120 NW 14TH ST STE 1263
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33136-2107
Mailing Address - Country:US
Mailing Address - Phone:305-243-3208
Mailing Address - Fax:305-243-0338
Practice Address - Street 1:1120 NW 14TH ST STE 1263
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33136-2107
Practice Address - Country:US
Practice Address - Phone:305-243-3208
Practice Address - Fax:305-243-0338
Is Sole Proprietor?:No
Enumeration Date:2005-10-25
Last Update Date:2024-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA76630207X00000X
FL166008207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAJ31083OtherBCBS MA
MA3133044Medicaid
MA737619OtherTUFTS HEALTH PLAN
MA737619OtherTUFTS HEALTH PLAN
MAJ31083OtherBCBS MA