Provider Demographics
NPI:1427184019
Name:VANDERGRIFF, MAURISE GENE SR (LDO)
Entity Type:Individual
Prefix:MR
First Name:MAURISE
Middle Name:GENE
Last Name:VANDERGRIFF
Suffix:SR
Gender:M
Credentials:LDO
Other - Prefix:
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Mailing Address - Street 1:2415 CHAMBLISS AVE NW
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:TN
Mailing Address - Zip Code:37311-3882
Mailing Address - Country:US
Mailing Address - Phone:423-479-4397
Mailing Address - Fax:423-476-2974
Practice Address - Street 1:2415 CHAMBLISS AVE NW
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:TN
Practice Address - Zip Code:37311-3882
Practice Address - Country:US
Practice Address - Phone:423-479-4397
Practice Address - Fax:423-476-2974
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-26
Last Update Date:2008-03-06
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TNDPO 319156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN2002794OtherBLUE CROSS & BLUE SHIELD
TN2002794OtherBLUE CROSS & BLUE SHIELD