Provider Demographics
NPI:1326326091
Name:GRISHAM, DAVID (OD, MS, FAAO,FCOVD-A)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:
Last Name:GRISHAM
Suffix:
Gender:M
Credentials:OD, MS, FAAO,FCOVD-A
Other - Prefix:DR
Other - First Name:JOHN
Other - Middle Name:DAVID
Other - Last Name:GRISHAM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:OD,MS,FAAO,FCOVA-A
Mailing Address - Street 1:615 B ST
Mailing Address - Street 2:SUITE 2
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94901-3805
Mailing Address - Country:US
Mailing Address - Phone:415-459-2020
Mailing Address - Fax:415-459-2021
Practice Address - Street 1:615 B ST
Practice Address - Street 2:SUITE 2
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94901-3805
Practice Address - Country:US
Practice Address - Phone:415-459-2020
Practice Address - Fax:415-459-2021
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-29
Last Update Date:2011-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA5110152WL0500X, 152WP0200X, 152WS0006X, 152WV0400X, 152WX0102X, 156FX1100X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WL0500XEye and Vision Services ProvidersOptometristLow Vision Rehabilitation
No152WP0200XEye and Vision Services ProvidersOptometristPediatrics
No152WS0006XEye and Vision Services ProvidersOptometristSports Vision
No152WV0400XEye and Vision Services ProvidersOptometristVision Therapy
No152WX0102XEye and Vision Services ProvidersOptometristOccupational Vision
No156FX1100XEye and Vision Services ProvidersTechnician/TechnologistOphthalmic