Healthcare Provider Details

I. General information

NPI: 1407141625
Provider Name (Legal Business Name): JONATHAN GRUBER D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/15/2011
Last Update Date: 06/03/2024
Certification Date: 06/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

34800 BOB WILSON DR
SAN DIEGO CA
92134-1098
US

IV. Provider business mailing address

819 ISLAND CT
SAN DIEGO CA
92109-7710
US

V. Phone/Fax

Practice location:
  • Phone: 619-532-6400
  • Fax:
Mailing address:
  • Phone: 304-520-9302
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number0102203227
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: