Provider Demographics
NPI:1447271473
Name:GROHOL, MARK PAUL (OD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:PAUL
Last Name:GROHOL
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 1:703 RUTTER AVE
Mailing Address - Street 2:
Mailing Address - City:KINGSTON
Mailing Address - State:PA
Mailing Address - Zip Code:18704-4801
Mailing Address - Country:US
Mailing Address - Phone:570-288-7405
Mailing Address - Fax:570-288-7406
Practice Address - Street 1:1720 E BROAD ST
Practice Address - Street 2:
Practice Address - City:HAZLETON
Practice Address - State:PA
Practice Address - Zip Code:18201-5622
Practice Address - Country:US
Practice Address - Phone:570-455-3391
Practice Address - Fax:570-455-9150
Is Sole Proprietor?:No
Enumeration Date:2006-07-23
Last Update Date:2014-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG000393152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
U61395Medicare UPIN
PA814014Medicare ID - Type Unspecified
PA0617860003Medicare NSC