Provider Demographics
NPI:1457848319
Name:GRANDELA, CARLOS L (OD)
Entity Type:Individual
Prefix:
First Name:CARLOS
Middle Name:L
Last Name:GRANDELA
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 1:3241 S MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60616-4201
Mailing Address - Country:US
Mailing Address - Phone:312-949-7751
Mailing Address - Fax:
Practice Address - Street 1:1830 S ALMA SCHOOL RD STE 131
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85210-3088
Practice Address - Country:US
Practice Address - Phone:480-924-8755
Practice Address - Fax:480-854-1864
Is Sole Proprietor?:No
Enumeration Date:2018-04-17
Last Update Date:2024-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046011198152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist