Provider Demographics
NPI:1780624700
Name:GRUNBAUM, LAURA (MD)
Entity type:Individual
Prefix:DR
First Name:LAURA
Middle Name:
Last Name:GRUNBAUM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:66 SHANNON CIR
Mailing Address - Street 2:
Mailing Address - City:ALAMEDA
Mailing Address - State:CA
Mailing Address - Zip Code:94502-7729
Mailing Address - Country:US
Mailing Address - Phone:510-435-0581
Mailing Address - Fax:
Practice Address - Street 1:1300 BANCROFT AVE
Practice Address - Street 2:SUITE 204
Practice Address - City:SAN LEANDRO
Practice Address - State:CA
Practice Address - Zip Code:94577-5147
Practice Address - Country:US
Practice Address - Phone:510-483-2600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2021-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG080985208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAYYY48935YMedicaid
CAYYY48935YMedicaid