Provider Demographics
NPI:1548778160
Name:DARRELL E GROMAN OD LLC
Entity Type:Organization
Organization Name:DARRELL E GROMAN OD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DARRELL
Authorized Official - Middle Name:EUGENE
Authorized Official - Last Name:GROMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:419-384-3275
Mailing Address - Street 1:204 HILTY DRIVE
Mailing Address - Street 2:P.O. BOX 209
Mailing Address - City:PANDORA
Mailing Address - State:OH
Mailing Address - Zip Code:45877-0209
Mailing Address - Country:US
Mailing Address - Phone:419-384-3275
Mailing Address - Fax:419-384-3285
Practice Address - Street 1:204 HILTY DRIVE
Practice Address - Street 2:
Practice Address - City:PANDORA
Practice Address - State:OH
Practice Address - Zip Code:45877-0209
Practice Address - Country:US
Practice Address - Phone:409-384-3275
Practice Address - Fax:419-384-3285
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-17
Last Update Date:2018-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152WV0400XEye and Vision Services ProvidersOptometristVision TherapyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0597420Medicaid