Basic Information
| Provider Information | |||||||||
| NPI: | 1225032998 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GRUBER | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | DAVID | ||||||||
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| Credential: | M D PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1970 E 3RD AVE | ||||||||
| Address2: | |||||||||
| City: | DURANGO | ||||||||
| State: | CO | ||||||||
| PostalCode: | 813015056 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9702472214 | ||||||||
| FaxNumber: | 9702473277 | ||||||||
| Practice Location | |||||||||
| Address1: | 106 BLANCA AVE STE 300 | ||||||||
| Address2: | |||||||||
| City: | ALAMOSA | ||||||||
| State: | CO | ||||||||
| PostalCode: | 811012340 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195893658 | ||||||||
| FaxNumber: | 7195890997 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/09/2005 | ||||||||
| LastUpdateDate: | 01/26/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/26/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 9459 | NM | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 13911 | 05 | NM | MEDICAID |