Provider Demographics
NPI:1144213083
Name:EDWARD H GRATTAN OD PC
Entity Type:Organization
Organization Name:EDWARD H GRATTAN OD PC
Other - Org Name:GRATTAN OPTOMETRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OPTOMETRIST OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:HOWARD
Authorized Official - Last Name:GRATTAN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:248-625-3500
Mailing Address - Street 1:20 W WASHINGTON ST
Mailing Address - Street 2:STE 7
Mailing Address - City:CLARKSON
Mailing Address - State:MI
Mailing Address - Zip Code:48346-1572
Mailing Address - Country:US
Mailing Address - Phone:248-625-3500
Mailing Address - Fax:248-625-0025
Practice Address - Street 1:20 W WASHINGTON ST
Practice Address - Street 2:STE 7
Practice Address - City:CLARKSON
Practice Address - State:MI
Practice Address - Zip Code:48346-1572
Practice Address - Country:US
Practice Address - Phone:248-625-3500
Practice Address - Fax:248-625-0025
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901002202152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
T33464Medicare UPIN