Basic Information
| Provider Information | |||||||||
| NPI: | 1447208715 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GROSSMAN | ||||||||
| FirstName: | RICHARD | ||||||||
| MiddleName: | ALAN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | O.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 488 PLEASANT ST | ||||||||
| Address2: | |||||||||
| City: | WORCESTER | ||||||||
| State: | MA | ||||||||
| PostalCode: | 016091857 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5087566832 | ||||||||
| FaxNumber: | 5087565266 | ||||||||
| Practice Location | |||||||||
| Address1: | 488 PLEASANT ST | ||||||||
| Address2: | |||||||||
| City: | WORCESTER | ||||||||
| State: | MA | ||||||||
| PostalCode: | 016091857 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5087566832 | ||||||||
| FaxNumber: | 5087565266 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/05/2006 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 2398 | MA | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | MG0334588M | 01 | MA | CONTROLLED SUBSTANCES REG | OTHER | 0325481 | 05 | MA | MEDICAID | 2398 | 01 | MA | STATE O.D. LICENSE | OTHER |