Provider Demographics
NPI:1275672917
Name:ROBERT A GRAND OD PA
Entity Type:Organization
Organization Name:ROBERT A GRAND OD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:A
Authorized Official - Last Name:GRAND
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:305-233-2040
Mailing Address - Street 1:8353 SW 124TH ST
Mailing Address - Street 2:SUITE 106
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33156-5851
Mailing Address - Country:US
Mailing Address - Phone:305-233-2040
Mailing Address - Fax:305-233-2052
Practice Address - Street 1:8353 SW 124TH ST
Practice Address - Street 2:SUITE 106
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33156-5851
Practice Address - Country:US
Practice Address - Phone:305-233-2040
Practice Address - Fax:305-233-2052
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-06
Last Update Date:2010-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC1222152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL078590300Medicaid
FL078590300Medicaid