Provider Demographics
NPI:1285721076
Name:GONZALES, CAROLYN GROUT (OD)
Entity type:Individual
Prefix:
First Name:CAROLYN
Middle Name:GROUT
Last Name:GONZALES
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:CAROLYN
Other - Middle Name:L
Other - Last Name:GROUT
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OD
Mailing Address - Street 1:10803 N NELSON RD
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99218-1629
Mailing Address - Country:US
Mailing Address - Phone:509-869-9538
Mailing Address - Fax:
Practice Address - Street 1:4407 N DIVISION ST STE 100
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99207-1670
Practice Address - Country:US
Practice Address - Phone:509-487-3838
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-05
Last Update Date:2022-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA00003086152W00000X
WA3086TX152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist