1619050895 NPI number — DR. ELIZABETH MOLLETTE GRUNDY PH.D.

Table of content: DR. ELIZABETH MOLLETTE GRUNDY PH.D. (NPI 1619050895)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619050895 NPI number — DR. ELIZABETH MOLLETTE GRUNDY PH.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GRUNDY
Provider First Name:
ELIZABETH
Provider Middle Name:
MOLLETTE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PH.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1619050895
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 426
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
VINITA
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
74301-0426
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
918-629-8664
Provider Business Mailing Address Fax Number:
918-782-4301

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1520 NORTH INDUSTRIAL ROAD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
VINITA
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
74301
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
918-629-8664
Provider Business Practice Location Address Fax Number:
918-782-4301
Provider Enumeration Date:
10/23/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103TH0100X , with the licence number:  750 , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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