Provider Demographics
NPI:1063191252
Name:RUP, GRADY PATRICK (OD)
Entity type:Individual
Prefix:DR
First Name:GRADY
Middle Name:PATRICK
Last Name:RUP
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 1:19792 HIGHWAY 105 W STE 300
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:TX
Mailing Address - Zip Code:77356-6107
Mailing Address - Country:US
Mailing Address - Phone:936-220-4313
Mailing Address - Fax:936-220-4312
Practice Address - Street 1:19792 HIGHWAY 105 W STE 300
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:TX
Practice Address - Zip Code:77356-6107
Practice Address - Country:US
Practice Address - Phone:936-220-4313
Practice Address - Fax:936-220-4312
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-14
Last Update Date:2025-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX10916152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist