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General NPI Number Information
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NPI Number | 1861596884
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Entity Type | Individual
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Provider Name | MATTHEW DAVID GRUCELLA OD
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Gender | Male
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Dates
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Enumeration Date | 09/11/2006
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Last Update Date | 11/04/2019
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Provider Practice Location Address
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Address Line | 1333 N CARPENTER RD
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City | BRUNSWICK
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State | OH
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Zip | 44212-3178
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Country | US
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Telephone | 330-741-3407
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Fax | 330-741-4037
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Provider Business Mailing Address
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Address Line | 1486 WATERBURY RD
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City | LAKEWOOD
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State | OH
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Zip | 44107-4817
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Country | US
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Telephone | 216-241-3210
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Fax | 216-241-2458
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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 | 5309
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License Number State | OH
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