Provider Demographics
NPI:1396599387
Name:GRUETT, KARLY ROSE (OD)
Entity type:Individual
Prefix:
First Name:KARLY
Middle Name:ROSE
Last Name:GRUETT
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:230 E DAY RD STE 100
Mailing Address - Street 2:
Mailing Address - City:MISHAWAKA
Mailing Address - State:IN
Mailing Address - Zip Code:46545-3408
Mailing Address - Country:US
Mailing Address - Phone:574-271-3939
Mailing Address - Fax:
Practice Address - Street 1:230 E DAY RD STE 100
Practice Address - Street 2:
Practice Address - City:MISHAWAKA
Practice Address - State:IN
Practice Address - Zip Code:46545-3408
Practice Address - Country:US
Practice Address - Phone:574-271-3939
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-15
Last Update Date:2025-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18004596A152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist