Provider Demographics
NPI:1003917030
Name:GRIMES, EDWARD L (OD)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:L
Last Name:GRIMES
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:PO BOX 22000
Mailing Address - Street 2:
Mailing Address - City:SAN ANGELO
Mailing Address - State:TX
Mailing Address - Zip Code:76902-7200
Mailing Address - Country:US
Mailing Address - Phone:325-658-1511
Mailing Address - Fax:325-481-2028
Practice Address - Street 1:4450 SUNSET DR
Practice Address - Street 2:
Practice Address - City:SAN ANGELO
Practice Address - State:TX
Practice Address - Zip Code:76901-5611
Practice Address - Country:US
Practice Address - Phone:325-481-2286
Practice Address - Fax:325-481-2028
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2010-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX3472TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX82781QOtherBCBS
TX82781QOtherBCBS
TX3472TGMedicare UPIN