Healthcare Provider Details

I. General information

NPI: 1306917554
Provider Name (Legal Business Name): ROBERT MARC GROSSMANN O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/10/2006
Last Update Date: 02/09/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 YORKTOWNE DR
DAYTONA BEACH FL
32119-1471
US

IV. Provider business mailing address

1070 GREENWOOD BLVD
LAKE MARY FL
32746-5404
US

V. Phone/Fax

Practice location:
  • Phone: 386-788-6696
  • Fax: 386-788-2219
Mailing address:
  • Phone: 407-333-5111
  • Fax: 407-333-2434

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPC1536
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: