Provider Demographics
NPI:1467590554
Name:GRANT, JOSEPH DALE (OD)
Entity Type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:DALE
Last Name:GRANT
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:PO BOX 337
Mailing Address - Street 2:
Mailing Address - City:LIMESTONE
Mailing Address - State:TN
Mailing Address - Zip Code:37681-0337
Mailing Address - Country:US
Mailing Address - Phone:423-257-2340
Mailing Address - Fax:423-257-8627
Practice Address - Street 1:364 OPIE ARNOLD ROAD
Practice Address - Street 2:
Practice Address - City:LIMESTONE
Practice Address - State:TN
Practice Address - Zip Code:37681-0337
Practice Address - Country:US
Practice Address - Phone:423-257-2340
Practice Address - Fax:423-257-8627
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-02
Last Update Date:2009-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNODT001064152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN86853OtherBLUE CROSS BLUE SHEILD
TN35688043Medicare PIN
TN86853OtherBLUE CROSS BLUE SHEILD