Provider Demographics
NPI:1467488569
Name:GRAVES, RICHARD A III (OD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:A
Last Name:GRAVES
Suffix:III
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 1:396 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PRESQUE ISLE
Mailing Address - State:ME
Mailing Address - Zip Code:04769-2601
Mailing Address - Country:US
Mailing Address - Phone:207-764-3185
Mailing Address - Fax:207-764-8621
Practice Address - Street 1:396 MAIN ST
Practice Address - Street 2:
Practice Address - City:PRESQUE ISLE
Practice Address - State:ME
Practice Address - Zip Code:04769-2601
Practice Address - Country:US
Practice Address - Phone:207-764-3185
Practice Address - Fax:207-764-8621
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-23
Last Update Date:2013-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEOPT539152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME119560000Medicaid
MET79602Medicare UPIN
ME119560000Medicaid