Healthcare Provider Details

I. General information

NPI: 1023797503
Provider Name (Legal Business Name): GRIGOR MARTIROSYAN OD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/13/2023
Last Update Date: 08/04/2026
Certification Date: 08/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

63 MAIN ST
BROCKTON MA
02301-4042
US

IV. Provider business mailing address

63 MAIN ST
BROCKTON MA
02301-4042
US

V. Phone/Fax

Practice location:
  • Phone: 508-894-3444
  • Fax: 508-427-4294
Mailing address:
  • Phone: 508-894-3444
  • Fax: 508-427-4294

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number5626
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: