Provider Demographics
NPI:1386860443
Name:PHILLIP D GRIMES P C
Entity Type:Organization
Organization Name:PHILLIP D GRIMES P C
Other - Org Name:PHILLIP D. GRIMES, O.D.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PHILLIP
Authorized Official - Middle Name:DON
Authorized Official - Last Name:GRIMES
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:405-376-2429
Mailing Address - Street 1:1108 E. HIGHWAY 152
Mailing Address - Street 2:
Mailing Address - City:MUSTANG
Mailing Address - State:OK
Mailing Address - Zip Code:73064-5116
Mailing Address - Country:US
Mailing Address - Phone:405-376-2429
Mailing Address - Fax:405-376-2431
Practice Address - Street 1:1108 E. HIGHWAY 152
Practice Address - Street 2:
Practice Address - City:MUSTANG
Practice Address - State:OK
Practice Address - Zip Code:73064-5116
Practice Address - Country:US
Practice Address - Phone:405-376-2429
Practice Address - Fax:405-376-2431
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-17
Last Update Date:2011-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK845152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK410048647OtherRAILROAD MEDICARE NSC
OK=========001OtherBLUE CROSS BLUE SHIELD
OK410048647OtherRAILROAD MEDICARE NSC