Provider Demographics
NPI:1497853782
Name:GRANGER, BRYAN (OD)
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:
Last Name:GRANGER
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 1254
Mailing Address - Street 2:
Mailing Address - City:BROUSSARD
Mailing Address - State:LA
Mailing Address - Zip Code:70518-1254
Mailing Address - Country:US
Mailing Address - Phone:337-364-0425
Mailing Address - Fax:337-364-0426
Practice Address - Street 1:1612 E MAIN ST
Practice Address - Street 2:SUITE C
Practice Address - City:NEW IBERIA
Practice Address - State:LA
Practice Address - Zip Code:70560-4065
Practice Address - Country:US
Practice Address - Phone:337-364-0425
Practice Address - Fax:337-364-0426
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1366-535T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist