Provider Demographics
NPI:1811983745
Name:GROTE, WALTER R (DO)
Entity type:Individual
Prefix:
First Name:WALTER
Middle Name:R
Last Name:GROTE
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 1:532 LAFAYETTE RD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:SPARTA
Mailing Address - State:NJ
Mailing Address - Zip Code:07871-4411
Mailing Address - Country:US
Mailing Address - Phone:973-940-0423
Mailing Address - Fax:973-940-0399
Practice Address - Street 1:532 LAFAYETTE RD
Practice Address - Street 2:SUITE 300
Practice Address - City:SPARTA
Practice Address - State:NJ
Practice Address - Zip Code:07871-4411
Practice Address - Country:US
Practice Address - Phone:980-263-9601
Practice Address - Fax:980-263-9601
Is Sole Proprietor?:No
Enumeration Date:2005-09-26
Last Update Date:2022-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB03954800207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0341401Medicaid
NJ485624Medicare PIN
NJC54086Medicare UPIN
NJ485624PXEMedicare PIN
NJ0341401Medicare PIN
NJ0341401Medicaid
NJGR485624Medicare Oscar/Certification