Provider Demographics
NPI:1275938557
Name:GRIFKA, CORY A (OD)
Entity Type:Individual
Prefix:
First Name:CORY
Middle Name:A
Last Name:GRIFKA
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 1:945 S MESA HILLS DR APT 3709
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79912-5157
Mailing Address - Country:US
Mailing Address - Phone:231-287-7669
Mailing Address - Fax:
Practice Address - Street 1:1240 LOMALAND DR
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79907-1405
Practice Address - Country:US
Practice Address - Phone:915-591-4441
Practice Address - Fax:915-591-0142
Is Sole Proprietor?:No
Enumeration Date:2014-10-28
Last Update Date:2015-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX8822T152W00000X
SC1830152W00000X, 152WC0802X, 152WL0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152WL0500XEye and Vision Services ProvidersOptometristLow Vision Rehabilitation