Provider Demographics
NPI:1548351034
Name:GRANT, DAVID GLENN (OD)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:GLENN
Last Name:GRANT
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
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Mailing Address - Street 1:1501 S RANGE LINE RD
Mailing Address - Street 2:
Mailing Address - City:JOPLIN
Mailing Address - State:MO
Mailing Address - Zip Code:64804-3230
Mailing Address - Country:US
Mailing Address - Phone:417-781-7010
Mailing Address - Fax:417-781-7009
Practice Address - Street 1:1501 S RANGE LINE RD
Practice Address - Street 2:
Practice Address - City:JOPLIN
Practice Address - State:MO
Practice Address - Zip Code:64804-3230
Practice Address - Country:US
Practice Address - Phone:417-781-7010
Practice Address - Fax:417-781-7009
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MOTO2953152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOU48685Medicare UPIN