Provider Demographics
NPI:1437247038
Name:LAWRENCE, GRANVILLE PAGE (OD)
Entity Type:Individual
Prefix:DR
First Name:GRANVILLE
Middle Name:PAGE
Last Name:LAWRENCE
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 1:3252 WEST LAKE STREET #A
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55416-5374
Mailing Address - Country:US
Mailing Address - Phone:612-926-2878
Mailing Address - Fax:612-920-4303
Practice Address - Street 1:3252 WEST LAKE STREET #A
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55416-5374
Practice Address - Country:US
Practice Address - Phone:612-926-2878
Practice Address - Fax:612-920-4303
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-10
Last Update Date:2022-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNMN1629152W00000X
MN1629152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1114045732OtherGROUP NPI
MNT39550Medicare UPIN
MNP004444770Medicare PIN