Provider Demographics
NPI:1871603670
Name:GRENN, GORDON L
Entity type:Individual
Prefix:
First Name:GORDON
Middle Name:L
Last Name:GRENN
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 1:4002 RAULERSON ROAD
Mailing Address - Street 2:
Mailing Address - City:LAKE WORTH
Mailing Address - State:FL
Mailing Address - Zip Code:33463-8927
Mailing Address - Country:US
Mailing Address - Phone:561-964-4077
Mailing Address - Fax:561-964-9296
Practice Address - Street 1:4002 RAULERSON DR
Practice Address - Street 2:
Practice Address - City:LAKE WORTH
Practice Address - State:FL
Practice Address - Zip Code:33463-8927
Practice Address - Country:US
Practice Address - Phone:561-964-4077
Practice Address - Fax:561-964-9296
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2011-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS0003345207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL265885200Medicaid
FL265885200Medicaid