Provider Demographics
NPI:1073008314
Name:GROTH, BENJAMIN RANDALL (OD)
Entity Type:Individual
Prefix:DR
First Name:BENJAMIN
Middle Name:RANDALL
Last Name:GROTH
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 1:6751 N 72ND ST STE 105
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68122-1746
Mailing Address - Country:US
Mailing Address - Phone:402-572-2020
Mailing Address - Fax:402-572-2150
Practice Address - Street 1:6751 N 72ND ST STE 105
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68122-1746
Practice Address - Country:US
Practice Address - Phone:402-572-2020
Practice Address - Fax:402-572-2150
Is Sole Proprietor?:No
Enumeration Date:2018-06-28
Last Update Date:2021-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA091798152W00000X
NE1530152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty