Provider Demographics
NPI:1861596884
Name:GRUCELLA, MATTHEW DAVID (OD)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:DAVID
Last Name:GRUCELLA
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 1:1486 WATERBURY RD
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:44107-4817
Mailing Address - Country:US
Mailing Address - Phone:216-241-3210
Mailing Address - Fax:216-241-2458
Practice Address - Street 1:1333 N CARPENTER RD
Practice Address - Street 2:
Practice Address - City:BRUNSWICK
Practice Address - State:OH
Practice Address - Zip Code:44212-3178
Practice Address - Country:US
Practice Address - Phone:330-741-3407
Practice Address - Fax:330-741-4037
Is Sole Proprietor?:No
Enumeration Date:2006-09-11
Last Update Date:2019-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH5309152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2345939Medicaid
OH4092231Medicare PIN
OH2345939Medicaid