Provider Demographics
NPI:1134968167
Name:GRUSZKA, SAMUEL ADAM
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:ADAM
Last Name:GRUSZKA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 S BELCHER RD
Mailing Address - Street 2:
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33764-6301
Mailing Address - Country:US
Mailing Address - Phone:727-266-2393
Mailing Address - Fax:727-266-2330
Practice Address - Street 1:148 13TH ST SW
Practice Address - Street 2:
Practice Address - City:LARGO
Practice Address - State:FL
Practice Address - Zip Code:33770-3127
Practice Address - Country:US
Practice Address - Phone:813-253-2727
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-20
Last Update Date:2024-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC6556152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLOPC6556OtherFLORIDA MEDICAL LICENSE