Provider Demographics
NPI:1649475450
Name:GROTJAHN, MICHAEL (MD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:
Last Name:GROTJAHN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:MICHAEL
Other - Middle Name:
Other - Last Name:GROTJAHN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 2609
Mailing Address - Street 2:
Mailing Address - City:MILL VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:94942-2609
Mailing Address - Country:US
Mailing Address - Phone:415-302-9640
Mailing Address - Fax:
Practice Address - Street 1:45 CAMINO ALTO AVE
Practice Address - Street 2:200
Practice Address - City:MILL VALLEY
Practice Address - State:CA
Practice Address - Zip Code:94941
Practice Address - Country:US
Practice Address - Phone:415-302-9640
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG135592084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry