Basic Information
| Provider Information | |||||||||
| NPI: | 1700899952 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GRASSO | ||||||||
| FirstName: | GINA | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | OD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1955 CITRACADO PKWY | ||||||||
| Address2: | STE 301 | ||||||||
| City: | ESCONDIDO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 920294113 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7607463937 | ||||||||
| FaxNumber: | 7607463991 | ||||||||
| Practice Location | |||||||||
| Address1: | 810 EAST OHIO AVENUE | ||||||||
| Address2: | |||||||||
| City: | ESCONDIDO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92025 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7607463937 | ||||||||
| FaxNumber: | 7607463991 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/15/2006 | ||||||||
| LastUpdateDate: | 02/09/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/09/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | OPT11139T | CA | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | WOP11139A | 05 | CA | MEDICAID |