Provider Demographics
NPI:1790725851
Name:GROSSBARD, ROGER N (OD)
Entity Type:Individual
Prefix:DR
First Name:ROGER
Middle Name:N
Last Name:GROSSBARD
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 1:17492 N HORSESHOE DR
Mailing Address - Street 2:
Mailing Address - City:SURPRISE
Mailing Address - State:AZ
Mailing Address - Zip Code:85374-6238
Mailing Address - Country:US
Mailing Address - Phone:623-975-4422
Mailing Address - Fax:
Practice Address - Street 1:14455 W GRAND AVE
Practice Address - Street 2:SUITE 102
Practice Address - City:SURPRISE
Practice Address - State:AZ
Practice Address - Zip Code:85374-7196
Practice Address - Country:US
Practice Address - Phone:623-546-2080
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2007-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1287152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZT22269Medicare UPIN
AZ107471Medicare ID - Type Unspecified