Provider Demographics
NPI:1396227575
Name:GRKINICH, ALYSSA NICOLE (OD)
Entity Type:Individual
Prefix:
First Name:ALYSSA
Middle Name:NICOLE
Last Name:GRKINICH
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:70 E 68TH PL
Mailing Address - Street 2:
Mailing Address - City:MERRILLVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46410-3506
Mailing Address - Country:US
Mailing Address - Phone:219-472-0361
Mailing Address - Fax:219-769-3884
Practice Address - Street 1:70 E 68TH PL
Practice Address - Street 2:
Practice Address - City:MERRILLVILLE
Practice Address - State:IN
Practice Address - Zip Code:46410-3506
Practice Address - Country:US
Practice Address - Phone:219-736-2020
Practice Address - Fax:219-769-3884
Is Sole Proprietor?:No
Enumeration Date:2018-09-04
Last Update Date:2018-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18004116A152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300018334Medicaid