Provider Demographics
NPI:1679538011
Name:GROTELUSCHEN, DAVID L (MD)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:L
Last Name:GROTELUSCHEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1726 SHAWANO AVE
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54303-3216
Mailing Address - Country:US
Mailing Address - Phone:920-884-3135
Mailing Address - Fax:920-884-3144
Practice Address - Street 1:1726 SHAWANO AVE
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54303-3216
Practice Address - Country:US
Practice Address - Phone:920-884-3135
Practice Address - Fax:920-884-3144
Is Sole Proprietor?:No
Enumeration Date:2006-04-19
Last Update Date:2021-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI44953207RX0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI34871500Medicaid
MI104894036Medicaid
MIDG088696OtherMICHIGAN BCBS
WII54466Medicare UPIN
MI104894036Medicaid