Provider Demographics
NPI:1417631292
Name:GROSS, CLARENCE ANTHONY JR (OPTICIAN)
Entity Type:Individual
Prefix:PROF
First Name:CLARENCE
Middle Name:ANTHONY
Last Name:GROSS
Suffix:JR
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 1:1101 RINEHART RD
Mailing Address - Street 2:
Mailing Address - City:SANFORD
Mailing Address - State:FL
Mailing Address - Zip Code:32771-7390
Mailing Address - Country:US
Mailing Address - Phone:407-302-8708
Mailing Address - Fax:407-302-8217
Practice Address - Street 1:1101 RINEHART RD
Practice Address - Street 2:
Practice Address - City:SANFORD
Practice Address - State:FL
Practice Address - Zip Code:32771-7390
Practice Address - Country:US
Practice Address - Phone:407-302-8708
Practice Address - Fax:407-302-8217
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-13
Last Update Date:2023-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDO5404156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician