MEDICARE: MATTHEW DAVID GRUCELLA OD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	5309	OH

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1861596884
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MATTHEW DAVID GRUCELLA OD

Provider Business Mailing Address
First Line	:	1486 WATERBURY RD
Second Line	:
City	:	LAKEWOOD
State	:	OH
Zip	:	44107-4817
Country	:	US
Telephone Number	:	216-241-3210
Fax Number	:	216-241-2458

Provider Business Practice Location Address
First Line	:	1333 N CARPENTER RD
Second Line	:
City	:	BRUNSWICK
State	:	OH
Zip	:	44212-3178
Country	:	US
Telephone Number	:	330-741-3407
Fax Number	:	330-741-4037

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/11/2006
Last Update Date	:	11/04/2019

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