Provider Demographics
NPI:1912932302
Name:GROSSMAN, DEVORA (OD)
Entity Type:Individual
Prefix:
First Name:DEVORA
Middle Name:
Last Name:GROSSMAN
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 1:200 WESTAGE BUSINESS CTR DR
Mailing Address - Street 2:
Mailing Address - City:FISHKILL
Mailing Address - State:NY
Mailing Address - Zip Code:12524-2264
Mailing Address - Country:US
Mailing Address - Phone:845-896-9280
Mailing Address - Fax:845-896-0246
Practice Address - Street 1:200 WESTAGE BUSINESS CTR DR
Practice Address - Street 2:
Practice Address - City:FISHKILL
Practice Address - State:NY
Practice Address - Zip Code:12524-2264
Practice Address - Country:US
Practice Address - Phone:845-896-9280
Practice Address - Fax:845-896-0246
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2015-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYT006559152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYV02454Medicare UPIN
NYC350H1Medicare ID - Type Unspecified