Provider Demographics
NPI:1427146372
Name:GRANGE, MATTHEW WILLIAM (OD)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:WILLIAM
Last Name:GRANGE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
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Mailing Address - Street 1:1340 DUCKWOOD DR
Mailing Address - Street 2:SUITE 14
Mailing Address - City:EAGAN
Mailing Address - State:MN
Mailing Address - Zip Code:55123-2324
Mailing Address - Country:US
Mailing Address - Phone:651-452-0344
Mailing Address - Fax:651-452-1564
Practice Address - Street 1:1340 DUCKWOOD DR
Practice Address - Street 2:SUITE 14
Practice Address - City:EAGAN
Practice Address - State:MN
Practice Address - Zip Code:55123-2324
Practice Address - Country:US
Practice Address - Phone:651-452-0344
Practice Address - Fax:651-452-1564
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MN3020000152W00000X, 152WC0802X, 152WP0200X, 152WS0006X, 152WX0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered152W00000XEye and Vision Services ProvidersOptometrist
Not Answered152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Not Answered152WP0200XEye and Vision Services ProvidersOptometristPediatrics
Not Answered152WS0006XEye and Vision Services ProvidersOptometristSports Vision
Not Answered152WX0102XEye and Vision Services ProvidersOptometristOccupational Vision
Provider Identifiers
StateIdentifier IDID TypeIssuer
2425242OtherAMERICAS PPO
MN86G79GROtherBLUE CROSS BLUE SHIELD
MNXX1901044875OtherPREFERRED ONE
MN2203255OtherMEDICA
MNHP60833OtherHEALTH PARTNERS
MN182595OtherUCARE
MG1394105OtherDEA
2425242OtherAMERICAS PPO
MN2203255OtherMEDICA