Provider Demographics
NPI:1144260175
Name:GRUSSO, MARK T (DPM)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:T
Last Name:GRUSSO
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:409 COVENTRY DR
Mailing Address - Street 2:
Mailing Address - City:PHILLIPSBURG
Mailing Address - State:NJ
Mailing Address - Zip Code:08865-1969
Mailing Address - Country:US
Mailing Address - Phone:908-213-0029
Mailing Address - Fax:908-213-9393
Practice Address - Street 1:409 COVENTRY DR
Practice Address - Street 2:
Practice Address - City:PHILLIPSBURG
Practice Address - State:NJ
Practice Address - Zip Code:08865-1969
Practice Address - Country:US
Practice Address - Phone:908-213-0029
Practice Address - Fax:908-213-9393
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2017-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMD01998213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0037702Medicaid
NJP00074810OtherRAILROAD MEDICARE
U17558Medicare UPIN
NJ0037702Medicaid