Provider Demographics
NPI:1245084276
Name:GRIGUERE, TARA (OD)
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:GRIGUERE
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 1:851 NE 1ST AVE UNIT 2004
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33132-1843
Mailing Address - Country:US
Mailing Address - Phone:786-583-5574
Mailing Address - Fax:
Practice Address - Street 1:358 SAN LORENZO AVE STE 2305
Practice Address - Street 2:
Practice Address - City:CORAL GABLES
Practice Address - State:FL
Practice Address - Zip Code:33146-1860
Practice Address - Country:US
Practice Address - Phone:786-526-5054
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-16
Last Update Date:2024-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
FLOPC6483152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program