Healthcare Provider Details

I. General information

NPI: 1821480732
Provider Name (Legal Business Name): MARY LEE GREWAL D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/02/2015
Last Update Date: 07/17/2026
Certification Date: 07/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11201 BENTON ST
LOMA LINDA CA
92357-3504
US

IV. Provider business mailing address

11201 BENTON ST
LOMA LINDA CA
92357-1000
US

V. Phone/Fax

Practice location:
  • Phone: 98-257-0849
  • Fax:
Mailing address:
  • Phone: 909-825-7084
  • Fax: 909-777-3209

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number19531
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: