Provider Demographics
NPI:1750484564
Name:GROSSMAN, SCOTT (OD PA)
Entity Type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:
Last Name:GROSSMAN
Suffix:
Gender:M
Credentials:OD PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18557 W DIXIE HWY
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33180-2614
Mailing Address - Country:US
Mailing Address - Phone:305-466-0777
Mailing Address - Fax:305-466-0773
Practice Address - Street 1:18557 W DIXIE HWY
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33180-2614
Practice Address - Country:US
Practice Address - Phone:305-466-0777
Practice Address - Fax:305-466-0773
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-07
Last Update Date:2012-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC4188152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL621143700Medicaid
FL621143700Medicaid