Provider Demographics
NPI:1205822590
Name:GROO, ELAINA M
Entity Type:Individual
Prefix:
First Name:ELAINA
Middle Name:M
Last Name:GROO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:304 FULLERTON AVE
Mailing Address - Street 2:
Mailing Address - City:NEWBURGH
Mailing Address - State:NY
Mailing Address - Zip Code:12550-3722
Mailing Address - Country:US
Mailing Address - Phone:845-565-2020
Mailing Address - Fax:
Practice Address - Street 1:304 FULLERTON AVE
Practice Address - Street 2:
Practice Address - City:NEWBURGH
Practice Address - State:NY
Practice Address - Zip Code:12550-3722
Practice Address - Country:US
Practice Address - Phone:845-565-2020
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-22
Last Update Date:2014-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV005487152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYU44886Medicare UPIN
C1A641Medicare PIN