Healthcare Provider Details

I. General information

NPI: 1235178674
Provider Name (Legal Business Name): DAVID W GRAMBOW MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/04/2006
Last Update Date: 06/12/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2350 N LAKE DR SUITE 400
MILWAUKEE WI
53211-4528
US

IV. Provider business mailing address

4425 N PORT WASHINGTON RD ATTN: CSMCP CLINIC CREDENTIALING
GLENDALE WI
53212-1082
US

V. Phone/Fax

Practice location:
  • Phone: 414-271-1633
  • Fax: 414-271-5071
Mailing address:
  • Phone: 414-271-1633
  • Fax: 414-271-5071

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number28836
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: