Basic Information
| Provider Information | |||||||||
| NPI: | 1366804494 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GRILLO | ||||||||
| FirstName: | LOLA | ||||||||
| MiddleName: | M. | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 725 | ||||||||
| Address2: | |||||||||
| City: | COOPERSTOWN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 133260725 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6075473456 | ||||||||
| FaxNumber: | 6075476612 | ||||||||
| Practice Location | |||||||||
| Address1: | 1415 ELM ST | ||||||||
| Address2: | |||||||||
| City: | MANCHESTER | ||||||||
| State: | NH | ||||||||
| PostalCode: | 031011325 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6036693925 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/28/2016 | ||||||||
| LastUpdateDate: | 05/19/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/19/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207W00000X | 21444 | NH | Y | Allopathic & Osteopathic Physicians | Ophthalmology |
No ID Information.