Provider Demographics
NPI:1760616478
Name:GROVER, BRIAN WILLIAM (OS)
Entity Type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:WILLIAM
Last Name:GROVER
Suffix:
Gender:M
Credentials:OS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2505 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:STRATFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06615-5839
Mailing Address - Country:US
Mailing Address - Phone:203-378-2281
Mailing Address - Fax:203-377-0233
Practice Address - Street 1:2505 MAIN ST
Practice Address - Street 2:
Practice Address - City:STRATFORD
Practice Address - State:CT
Practice Address - Zip Code:06615-5839
Practice Address - Country:US
Practice Address - Phone:203-378-2281
Practice Address - Fax:203-377-0233
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-08
Last Update Date:2009-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001123156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT0571050001Medicare NSC