MEDICARE: CALVIN GRUBBS III MD, FAAFP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	MD37496	SC
2	207Q00000X	Family Medicine Physician	MD61021807	WA
3	207Q00000X	Family Medicine Physician	28217	NE

General Provider Information

NPI Number	:	1487997169
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CALVIN GRUBBS III MD, FAAFP

Provider Business Mailing Address
First Line	:	4430 MISSOURI AVE
Second Line	:
City	:	FORT LEONARD WOOD
State	:	MO
Zip	:	65473-9098
Country	:	US
Telephone Number	:	573-596-1765
Fax Number	:

Provider Business Practice Location Address
First Line	:	9040A JACKSON AVE
Second Line	:
City	:	TACOMA
State	:	WA
Zip	:	98431-9098
Country	:	US
Telephone Number	:	253-968-1110
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/01/2013
Last Update Date	:	10/06/2021

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