Provider Demographics
NPI:1285690727
Name:GRANT, ROGER D (OD)
Entity Type:Individual
Prefix:DR
First Name:ROGER
Middle Name:D
Last Name:GRANT
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:216 N MERIDIAN RD
Mailing Address - Street 2:P.O. BOX 765
Mailing Address - City:NEWTON
Mailing Address - State:KS
Mailing Address - Zip Code:67114-5119
Mailing Address - Country:US
Mailing Address - Phone:316-283-1310
Mailing Address - Fax:316-283-1864
Practice Address - Street 1:216 N MERIDIAN RD
Practice Address - Street 2:
Practice Address - City:NEWTON
Practice Address - State:KS
Practice Address - Zip Code:67114-5119
Practice Address - Country:US
Practice Address - Phone:316-283-1310
Practice Address - Fax:316-283-1864
Is Sole Proprietor?:No
Enumeration Date:2006-04-25
Last Update Date:2007-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS0975-2152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS059697Medicare ID - Type UnspecifiedINDIVIDUAL NUMBER
KST71280Medicare UPIN
KS0201600001Medicare NSC