Healthcare Provider Details

I. General information

NPI: 1528031564
Provider Name (Legal Business Name): DARRELL EUGENE GROMAN O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/09/2006
Last Update Date: 03/05/2019
Certification Date:
Deactivation Date: 02/15/2018
Reactivation Date: 03/05/2019

III. Provider practice location address

204 HILTY DR.
PANDORA OH
45877-0209
US

IV. Provider business mailing address

PO BOX 209 204 HILTY DR.
PANDORA OH
45877-0209
US

V. Phone/Fax

Practice location:
  • Phone: 419-384-3275
  • Fax: 419-384-3285
Mailing address:
  • Phone: 419-384-3275
  • Fax: 419-384-3285

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152WV0400X
TaxonomyVision Therapy Optometrist
License Number3800/794
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: