Provider Demographics
NPI:1669714440
Name:GRUEZKE, ANDREW ALDEN
Entity type:Individual
Prefix:
First Name:ANDREW
Middle Name:ALDEN
Last Name:GRUEZKE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:246 BONNABEL BLVD
Mailing Address - Street 2:
Mailing Address - City:METAIRIE
Mailing Address - State:LA
Mailing Address - Zip Code:70005-3739
Mailing Address - Country:US
Mailing Address - Phone:504-650-7692
Mailing Address - Fax:
Practice Address - Street 1:246 BONNABEL BLVD
Practice Address - Street 2:
Practice Address - City:METAIRIE
Practice Address - State:LA
Practice Address - Zip Code:70005-3739
Practice Address - Country:US
Practice Address - Phone:504-650-7692
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-03-20
Last Update Date:2017-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
LAMD.207209208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program