Provider Demographics
NPI:1285620104
Name:GRUBBS, DUSTIN (OD)
Entity type:Individual
Prefix:MR
First Name:DUSTIN
Middle Name:
Last Name:GRUBBS
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 1:15933 CLAYTON RD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:BALLWIN
Mailing Address - State:MO
Mailing Address - Zip Code:63011-2172
Mailing Address - Country:US
Mailing Address - Phone:636-200-4393
Mailing Address - Fax:636-527-0838
Practice Address - Street 1:8050 NAVARRE PKWY
Practice Address - Street 2:
Practice Address - City:NAVARRE
Practice Address - State:FL
Practice Address - Zip Code:32566-6906
Practice Address - Country:US
Practice Address - Phone:850-939-3459
Practice Address - Fax:850-497-6219
Is Sole Proprietor?:No
Enumeration Date:2005-09-26
Last Update Date:2017-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC3475152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL20958OtherFLORIDA BLUE
FL620588700Medicaid
FL20958OtherFLORIDA BLUE
U85305Medicare UPIN