Provider Demographics
NPI:1831105691
Name:GRINSPAN, MARINA (OD)
Entity Type:Individual
Prefix:DR
First Name:MARINA
Middle Name:
Last Name:GRINSPAN
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 1:1 HIGHLAND AVE
Mailing Address - Street 2:
Mailing Address - City:MALDEN
Mailing Address - State:MA
Mailing Address - Zip Code:02148-6603
Mailing Address - Country:US
Mailing Address - Phone:781-321-9039
Mailing Address - Fax:
Practice Address - Street 1:1 HIGHLAND AVE # 3B
Practice Address - Street 2:
Practice Address - City:MALDEN
Practice Address - State:MA
Practice Address - Zip Code:02148-6603
Practice Address - Country:US
Practice Address - Phone:781-321-9039
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2019-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV0059121152W00000X
MA5274152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYBB1203Medicare ID - Type Unspecified
U70905Medicare UPIN