Provider Demographics
NPI:1447273610
Name:GRUDIS, TOM X (OPTICIAN)
Entity type:Individual
Prefix:
First Name:TOM
Middle Name:X
Last Name:GRUDIS
Suffix:
Gender:M
Credentials:OPTICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:428 SPRUCE ST
Mailing Address - Street 2:
Mailing Address - City:SCRANTON
Mailing Address - State:PA
Mailing Address - Zip Code:18503-1821
Mailing Address - Country:US
Mailing Address - Phone:570-346-1771
Mailing Address - Fax:570-346-5812
Practice Address - Street 1:428 SPRUCE ST
Practice Address - Street 2:
Practice Address - City:SCRANTON
Practice Address - State:PA
Practice Address - Zip Code:18503-1821
Practice Address - Country:US
Practice Address - Phone:570-346-1771
Practice Address - Fax:570-346-5812
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2008-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0498520001OtherMEDICARE PART B