Provider Demographics
NPI:1407904790
Name:GRIDER, DANNY ROBERT (OD)
Entity Type:Individual
Prefix:DR
First Name:DANNY
Middle Name:ROBERT
Last Name:GRIDER
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 1:2807 N VERMILION ST
Mailing Address - Street 2:SUITE #4
Mailing Address - City:DANVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:61832-1444
Mailing Address - Country:US
Mailing Address - Phone:217-446-5554
Mailing Address - Fax:217-446-5554
Practice Address - Street 1:2807 N VERMILION ST
Practice Address - Street 2:SUITE #4
Practice Address - City:DANVILLE
Practice Address - State:IL
Practice Address - Zip Code:61832-1444
Practice Address - Country:US
Practice Address - Phone:217-446-5554
Practice Address - Fax:217-446-5554
Is Sole Proprietor?:No
Enumeration Date:2007-01-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
311740Medicare ID - Type Unspecified
U03045Medicare UPIN