Healthcare Provider Details

I. General information

NPI: 1710991849
Provider Name (Legal Business Name): ELIZABETH A GRONINGER O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/27/2006
Last Update Date: 07/22/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 EDWARDS DR
PLAINFIELD IN
46168-5680
US

IV. Provider business mailing address

900 EDWARDS DR
PLAINFIELD IN
46168-5680
US

V. Phone/Fax

Practice location:
  • Phone: 317-839-2368
  • Fax: 317-839-1267
Mailing address:
  • Phone: 317-839-2368
  • Fax: 317-839-2338

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number18002476
License Number StateIN

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier11478976
Identifier TypeOTHER
Identifier StateIN
Identifier IssuerCAQH
# 2
Identifier000000083757
Identifier TypeOTHER
Identifier StateIN
Identifier IssuerANTHEM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: