Provider Demographics
NPI:1346398112
Name:GRATTAN, KENNETH VERNON (OD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:VERNON
Last Name:GRATTAN
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 1:7683 MACEDAY LAKE RD
Mailing Address - Street 2:
Mailing Address - City:WATERFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48329-2631
Mailing Address - Country:US
Mailing Address - Phone:248-623-9035
Mailing Address - Fax:
Practice Address - Street 1:400 BROWN RD
Practice Address - Street 2:
Practice Address - City:AUBURN HILLS
Practice Address - State:MI
Practice Address - Zip Code:48326-1305
Practice Address - Country:US
Practice Address - Phone:248-648-0003
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901002307152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist