Provider Demographics
NPI:1336820547
Name:GROVENBURG, WILLIAM MARTIN (OD)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:MARTIN
Last Name:GROVENBURG
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 1:11730 E 119TH ST N
Mailing Address - Street 2:
Mailing Address - City:COLLINSVILLE
Mailing Address - State:OK
Mailing Address - Zip Code:74021-1022
Mailing Address - Country:US
Mailing Address - Phone:719-200-3931
Mailing Address - Fax:
Practice Address - Street 1:1103 W CENTER ST
Practice Address - Street 2:
Practice Address - City:COLLINSVILLE
Practice Address - State:OK
Practice Address - Zip Code:74021-3108
Practice Address - Country:US
Practice Address - Phone:918-371-3339
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-31
Last Update Date:2024-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3225152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty