MEDICARE: DR. DAVID LAWRENCE DE GROH D.O.

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	34.002813	OH

General Provider Information

NPI Number	:	1699786608
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DAVID LAWRENCE DE GROH D.O.

Provider Business Mailing Address
First Line	:	3416 COLUMBUS AVE
Second Line	:
City	:	SANDUSKY
State	:	OH
Zip	:	44870-5557
Country	:	US
Telephone Number	:	419-625-7350
Fax Number	:	419-625-6660

Provider Business Practice Location Address
First Line	:	3416 COLUMBUS AVE
Second Line	:
City	:	SANDUSKY
State	:	OH
Zip	:	44870-5557
Country	:	US
Telephone Number	:	419-625-7350
Fax Number	:	419-625-6660

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

Provider Enumeration Date	:	08/11/2006
Last Update Date	:	09/07/2023

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