Provider Demographics
NPI:1720509458
Name:MILLER, GRANT THOMAS (OD)
Entity type:Individual
Prefix:DR
First Name:GRANT
Middle Name:THOMAS
Last Name:MILLER
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 1:2951 N TALMAN AVE APT 3F
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60618-7837
Mailing Address - Country:US
Mailing Address - Phone:812-767-4034
Mailing Address - Fax:
Practice Address - Street 1:8362 GRAND AVE
Practice Address - Street 2:
Practice Address - City:RIVER GROVE
Practice Address - State:IL
Practice Address - Zip Code:60171
Practice Address - Country:US
Practice Address - Phone:708-583-1100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-03
Last Update Date:2019-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046011216152W00000X, 152WL0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WL0500XEye and Vision Services ProvidersOptometristLow Vision Rehabilitation