Provider Demographics
NPI:1447208715
Name:GROSSMAN, RICHARD ALAN (OD)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:ALAN
Last Name:GROSSMAN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:488 PLEASANT ST
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01609-1857
Mailing Address - Country:US
Mailing Address - Phone:508-756-6832
Mailing Address - Fax:508-756-5266
Practice Address - Street 1:488 PLEASANT ST
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01609-1857
Practice Address - Country:US
Practice Address - Phone:508-756-6832
Practice Address - Fax:508-756-5266
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2398152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAMG0334588MOtherCONTROLLED SUBSTANCES REG
MA0325481Medicaid
MA2398OtherSTATE O.D. LICENSE
MA432658Medicare ID - Type UnspecifiedMEDICARE PROVIDER #
MAMG0334588MOtherCONTROLLED SUBSTANCES REG