Healthcare Provider Details

I. General information

NPI: 1316386840
Provider Name (Legal Business Name): LEAH D GROTTON O.D
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/18/2013
Last Update Date: 06/18/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

58 STATE ST
AUGUSTA ME
04330-5124
US

IV. Provider business mailing address

14 DRESSER RD
SCARBOROUGH ME
04074-9767
US

V. Phone/Fax

Practice location:
  • Phone: 207-623-5099
  • Fax: 207-623-7124
Mailing address:
  • Phone: 207-318-8741
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPT938
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: