Provider Demographics
NPI:1124027248
Name:GRANEK, BRIAN MICHAEL (OD)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:MICHAEL
Last Name:GRANEK
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 1:10995 OWINGS MILLS BOULEVARD
Mailing Address - Street 2:SUITE 204
Mailing Address - City:OWINGS MILLS
Mailing Address - State:MD
Mailing Address - Zip Code:21117-1030
Mailing Address - Country:US
Mailing Address - Phone:410-363-0060
Mailing Address - Fax:410-363-0911
Practice Address - Street 1:10995 OWINGS MILLS BOULEVARD
Practice Address - Street 2:SUITE 204
Practice Address - City:OWINGS MILLS
Practice Address - State:MD
Practice Address - Zip Code:21117-1030
Practice Address - Country:US
Practice Address - Phone:410-363-0060
Practice Address - Fax:410-363-0911
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-20
Last Update Date:2012-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDTA1751152W00000X
MDTA-1751152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDK892F985Medicare ID - Type Unspecified
MDU92682Medicare UPIN