Provider Demographics
NPI:1861414831
Name:GRUBER, REGINA A (MD)
Entity type:Individual
Prefix:
First Name:REGINA
Middle Name:A
Last Name:GRUBER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1037 MAIN ST
Mailing Address - Street 2:CREDENTIALING
Mailing Address - City:PEEKSKILL
Mailing Address - State:NY
Mailing Address - Zip Code:10566-2913
Mailing Address - Country:US
Mailing Address - Phone:914-734-8858
Mailing Address - Fax:914-734-8786
Practice Address - Street 1:888 PULASKI HWY
Practice Address - Street 2:
Practice Address - City:GOSHEN
Practice Address - State:NY
Practice Address - Zip Code:10924-6034
Practice Address - Country:US
Practice Address - Phone:845-651-2298
Practice Address - Fax:845-651-2299
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2010-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY220741208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02337382Medicaid
NY00473038Medicaid