Healthcare Provider Details

I. General information

NPI: 1699941781
Provider Name (Legal Business Name): KONRAD IZUMI GRUSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/07/2008
Last Update Date: 10/11/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1250 WATERS PL 11TH FLOOR
BRONX NY
10461-2720
US

IV. Provider business mailing address

1250 WATERS PL 11TH FLOOR
BRONX NY
10461-2720
US

V. Phone/Fax

Practice location:
  • Phone: 718-920-2060
  • Fax: 347-577-4428
Mailing address:
  • Phone: 718-920-2060
  • Fax: 347-577-4428

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number229650
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: