Provider Demographics
NPI:1669433165
Name:VANGROUW, BRIAN PETER (DO)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:PETER
Last Name:VANGROUW
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28-04 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:FAIR LAWN
Mailing Address - State:NJ
Mailing Address - Zip Code:07410-3920
Mailing Address - Country:US
Mailing Address - Phone:201-791-4434
Mailing Address - Fax:201-791-3423
Practice Address - Street 1:28-04 BROADWAY
Practice Address - Street 2:
Practice Address - City:FAIR LAWN
Practice Address - State:NJ
Practice Address - Zip Code:07410-3920
Practice Address - Country:US
Practice Address - Phone:201-791-4434
Practice Address - Fax:201-791-3423
Is Sole Proprietor?:No
Enumeration Date:2006-04-01
Last Update Date:2021-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMB055905207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ200025963OtherRAILROAD MEDICARE
NJ2856204Medicaid
NJ5936044OtherAETNA PPO
NJP558962OtherOXFORD
0500620001OtherNHIC, CORP.
GR769308Medicare PIN
NJ200025963OtherRAILROAD MEDICARE