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General NPI Number Information
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NPI Number | 1124011085
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Entity Type | Individual
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Provider Name | MATTHEW B GRUNDFAST D.O.
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Gender | Male
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Dates
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Enumeration Date | 08/25/2005
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Last Update Date | 05/25/2022
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Provider Practice Location Address
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Address Line | 111 FAIRVIEW PARK DR
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City | DUBLIN
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State | GA
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Zip | 31021-2501
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Country | US
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Telephone | 478-277-1929
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Fax | 478-304-1468
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Provider Business Mailing Address
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Address Line | 130 E WESTERLEE DR
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City | LEESBURG
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State | GA
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Zip | 31763-5817
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Country | US
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Telephone | 229-886-5150
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Fax | 682-200-2084
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207RG0100X
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Taxonomy Name | Gastroenterology Physician
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License Number | 052944
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License Number State | GA
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