Provider Demographics
NPI:1144378480
Name:GRANT, WILLIAM III (OD)
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:
Last Name:GRANT
Suffix:III
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 1:19595 HOUSTON RD
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:MO
Mailing Address - Zip Code:65536-8252
Mailing Address - Country:US
Mailing Address - Phone:417-532-9613
Mailing Address - Fax:
Practice Address - Street 1:19595 HOUSTON RD
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:MO
Practice Address - Zip Code:65536-8252
Practice Address - Country:US
Practice Address - Phone:417-532-9613
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-05
Last Update Date:2014-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOT02677152W00000X
GAOPT002207152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOT42661Medicare UPIN