Healthcare Provider Details

I. General information

NPI: 1962859686
Provider Name (Legal Business Name): THEODORE ERWIN GRASK M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2016
Last Update Date: 06/02/2023
Certification Date: 06/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

HOSPITAL AMERICANO BASE NAVAL DE ROTA APARTADO DE CORREOS 33
ROTA CADIZ
11530
ES

IV. Provider business mailing address

PSC 819 BOX 18
FPO AE
09645-0001
US

V. Phone/Fax

Practice location:
  • Phone: 314-727-1923
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberMD-44458
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: