Provider Demographics
NPI:1780662338
Name:GROSSETT, SANDRA LEE (OD)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:LEE
Last Name:GROSSETT
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2527 COWAN BLVD
Mailing Address - Street 2:
Mailing Address - City:FREDERICKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:22401-8440
Mailing Address - Country:US
Mailing Address - Phone:540-369-3482
Mailing Address - Fax:540-372-9604
Practice Address - Street 1:2527 COWAN BLVD
Practice Address - Street 2:
Practice Address - City:FREDERICKSBURG
Practice Address - State:VA
Practice Address - Zip Code:22401-8440
Practice Address - Country:US
Practice Address - Phone:540-369-3482
Practice Address - Fax:540-372-9604
Is Sole Proprietor?:No
Enumeration Date:2006-01-04
Last Update Date:2017-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618000263152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
U43698Medicare UPIN