Healthcare Provider Details

I. General information

NPI: 1780624700
Provider Name (Legal Business Name): LAURA GRUNBAUM M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/07/2006
Last Update Date: 12/17/2021
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1300 BANCROFT AVE SUITE 204
SAN LEANDRO CA
94577-5147
US

IV. Provider business mailing address

66 SHANNON CIR
ALAMEDA CA
94502-7729
US

V. Phone/Fax

Practice location:
  • Phone: 510-483-2600
  • Fax:
Mailing address:
  • Phone: 510-435-0581
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberG080985
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: