Provider Demographics
NPI:1518938117
Name:GRONQUIST, JOANNE (OD)
Entity Type:Individual
Prefix:DR
First Name:JOANNE
Middle Name:
Last Name:GRONQUIST
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 1:1805 STATE ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:SANTA BARBARA
Mailing Address - State:CA
Mailing Address - Zip Code:93101-8415
Mailing Address - Country:US
Mailing Address - Phone:805-569-1504
Mailing Address - Fax:805-569-8707
Practice Address - Street 1:1805 STATE ST
Practice Address - Street 2:SUITE B
Practice Address - City:SANTA BARBARA
Practice Address - State:CA
Practice Address - Zip Code:93101-8415
Practice Address - Country:US
Practice Address - Phone:805-569-1504
Practice Address - Fax:805-569-8707
Is Sole Proprietor?:No
Enumeration Date:2006-01-31
Last Update Date:2007-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10965T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA10965TOtherCA STATE LICENSE NUMBER
CAV04037Medicare UPIN
CAWOP10965AMedicare PIN