Healthcare Provider Details

I. General information

NPI: 1316148646
Provider Name (Legal Business Name): ROBERT B GRZYWACZ DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/31/2007
Last Update Date: 05/23/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3221 E WARM SPRINGS RD
LAS VEGAS NV
89120-3157
US

IV. Provider business mailing address

3221 E WARM SPRINGS RD
LAS VEGAS NV
89120-3157
US

V. Phone/Fax

Practice location:
  • Phone: 702-733-7617
  • Fax: 702-733-1732
Mailing address:
  • Phone: 702-733-7617
  • Fax: 702-733-1732

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number793965375
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: