Provider Demographics
NPI:1801903042
Name:GRUNDMEYER, WAYNE ALVIN (MD)
Entity type:Individual
Prefix:DR
First Name:WAYNE
Middle Name:ALVIN
Last Name:GRUNDMEYER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 MEADOWCREST ST
Mailing Address - Street 2:#220
Mailing Address - City:GRETNA
Mailing Address - State:LA
Mailing Address - Zip Code:70056-5255
Mailing Address - Country:US
Mailing Address - Phone:504-391-7595
Mailing Address - Fax:504-391-7599
Practice Address - Street 1:120 MEADOWCREST ST
Practice Address - Street 2:#220
Practice Address - City:GRETNA
Practice Address - State:LA
Practice Address - Zip Code:70056-5255
Practice Address - Country:US
Practice Address - Phone:504-391-7595
Practice Address - Fax:504-391-7599
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD 014877174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1324299Medicaid
B64193Medicare UPIN
LA1324299Medicaid