Provider Demographics
NPI:1720012008
Name:GRISE, DARRELL SCOTT (OD)
Entity Type:Individual
Prefix:DR
First Name:DARRELL
Middle Name:SCOTT
Last Name:GRISE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:307 BOATNER RD
Mailing Address - Street 2:SUITE 114
Mailing Address - City:EGLIN AFB
Mailing Address - State:FL
Mailing Address - Zip Code:32542-1391
Mailing Address - Country:US
Mailing Address - Phone:850-883-9472
Mailing Address - Fax:850-883-1267
Practice Address - Street 1:307 BOATNER RD
Practice Address - Street 2:SUITE 114
Practice Address - City:EGLIN AFB
Practice Address - State:FL
Practice Address - Zip Code:32542-1391
Practice Address - Country:US
Practice Address - Phone:850-883-9472
Practice Address - Fax:850-883-1267
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2007-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA3647152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist