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General NPI Number Information
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NPI Number | 1720012008
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Entity Type | Individual
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Provider Name | DARRELL SCOTT GRISE O.D.
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Gender | Male
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Dates
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Enumeration Date | 07/10/2006
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Last Update Date | 10/10/2007
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Provider Practice Location Address
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Address Line | 307 BOATNER RD SUITE 114
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City | EGLIN AFB
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State | FL
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Zip | 32542-1391
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Country | US
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Telephone | 850-883-9472
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Fax | 850-883-1267
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Provider Business Mailing Address
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Address Line | 307 BOATNER RD SUITE 114
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City | EGLIN AFB
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State | FL
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Zip | 32542-1391
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Country | US
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Telephone | 850-883-9472
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Fax | 850-883-1267
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 3647
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License Number State | MA
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