Healthcare Provider Details

I. General information

NPI: 1831112317
Provider Name (Legal Business Name): STEPHEN M GROSS O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/25/2006
Last Update Date: 04/01/2020
Certification Date: 04/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

166 LINDBERG AVE
ATMORE AL
36502-3206
US

IV. Provider business mailing address

10184 EASTERN SHORE BLVD STE A
SPANISH FORT AL
36527-5814
US

V. Phone/Fax

Practice location:
  • Phone: 251-368-8767
  • Fax: 251-368-4565
Mailing address:
  • Phone: 251-368-8767
  • Fax: 251-368-4565

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberS486TA041
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: