Healthcare Provider Details

I. General information

NPI: 1689665093
Provider Name (Legal Business Name): ROBERT J GRASS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/03/2005
Last Update Date: 10/18/2024
Certification Date: 10/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

420 E DIVISION ST
FOND DU LAC WI
54935-4560
US

IV. Provider business mailing address

420 E DIVISION ST
FOND DU LAC WI
54935-4560
US

V. Phone/Fax

Practice location:
  • Phone: 920-926-8615
  • Fax:
Mailing address:
  • Phone: 920-926-8340
  • Fax: 920-926-8370

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RA0000X
TaxonomyAdolescent Medicine (Internal Medicine) Physician
License Number43234
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number43234
License Number StateWI
# 3
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number43234
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: