Provider Demographics
NPI:1902857113
Name:GROOM, MIMI (MD)
Entity Type:Individual
Prefix:
First Name:MIMI
Middle Name:
Last Name:GROOM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3455 PINE RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34109-3824
Mailing Address - Country:US
Mailing Address - Phone:239-597-5700
Mailing Address - Fax:
Practice Address - Street 1:3455 PINE RIDGE RD
Practice Address - Street 2:
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34109-3824
Practice Address - Country:US
Practice Address - Phone:239-597-5700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2016-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLFLME0065790207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL25861WMedicare PIN
FL25861YMedicare ID - Type Unspecified
FLF79607Medicare UPIN