Provider Demographics
NPI:1003904988
Name:GROSSMAN, MARC ROBERT (OD)
Entity Type:Individual
Prefix:DR
First Name:MARC
Middle Name:ROBERT
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 1:3 PARADIES LN
Mailing Address - Street 2:
Mailing Address - City:NEW PALTZ
Mailing Address - State:NY
Mailing Address - Zip Code:12561-4017
Mailing Address - Country:US
Mailing Address - Phone:845-255-3728
Mailing Address - Fax:845-255-0036
Practice Address - Street 1:3 PARADIES LN
Practice Address - Street 2:
Practice Address - City:NEW PALTZ
Practice Address - State:NY
Practice Address - Zip Code:12561-4017
Practice Address - Country:US
Practice Address - Phone:845-255-3728
Practice Address - Fax:845-255-0036
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY3873152W00000X, 152WV0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered152W00000XEye and Vision Services ProvidersOptometrist
Not Answered152WV0400XEye and Vision Services ProvidersOptometristVision Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYC32641Medicare ID - Type UnspecifiedOPTOMETRIST