Provider Demographics
NPI:1710161716
Name:GRUCHALA, ROBERT JOSEPH (FNAO)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:JOSEPH
Last Name:GRUCHALA
Suffix:
Gender:M
Credentials:FNAO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6200 CHIPPEWA ST
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63109-2115
Mailing Address - Country:US
Mailing Address - Phone:314-352-6100
Mailing Address - Fax:314-752-3404
Practice Address - Street 1:6200 CHIPPEWA
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63109-2238
Practice Address - Country:US
Practice Address - Phone:314-352-6100
Practice Address - Fax:314-752-3404
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-27
Last Update Date:2008-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO11078022156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO0655410001Medicare NSC