Provider Demographics
NPI:1720494248
Name:GRITSAEV, ANETA (OD)
Entity Type:Individual
Prefix:
First Name:ANETA
Middle Name:
Last Name:GRITSAEV
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:ANETA
Other - Middle Name:
Other - Last Name:SAMBORSKA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7200 HARRISON AVE
Mailing Address - Street 2:UNIT E 265
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61112-1017
Mailing Address - Country:US
Mailing Address - Phone:815-332-2223
Mailing Address - Fax:
Practice Address - Street 1:7200 HARRISON AVE
Practice Address - Street 2:UNIT E 265
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61112-1017
Practice Address - Country:US
Practice Address - Phone:815-332-2223
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-03
Last Update Date:2014-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046.010798152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist