Provider Demographics
NPI:1275618183
Name:GRAVES, GREGARY W (OD)
Entity Type:Individual
Prefix:
First Name:GREGARY
Middle Name:W
Last Name:GRAVES
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 1:2780 AIRPORT DR
Mailing Address - Street 2:STE 100
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43219-2289
Mailing Address - Country:US
Mailing Address - Phone:614-859-1906
Mailing Address - Fax:614-645-5517
Practice Address - Street 1:1180 E MAIN ST
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43205-1902
Practice Address - Country:US
Practice Address - Phone:614-645-5540
Practice Address - Fax:614-645-5300
Is Sole Proprietor?:No
Enumeration Date:2006-10-26
Last Update Date:2018-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4646152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0183902Medicaid
U61060Medicare UPIN
OH0183902Medicaid
OH2023431Medicare PIN