Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223G0001X | General Practice | DI016669 | NJ |
Y | 213EG0000X | General Practice | DI016669 | NJ |
NPI | 1003093196 |
---|---|
Provider Name | Dr. Bruce Jeffrey Grimaldi |
First Address | Summit, NJ 07901-2813 |
Second Address | Summit, NJ 07901-2813 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 30/01/2008 |
Last Update Date | 30/01/2008 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
U30839 | (02) | NJ |