Provider Demographics
NPI:1508893694
Name:GRATWOHL, DOUGLAS HENRY (OD)
Entity Type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:HENRY
Last Name:GRATWOHL
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 1:215 W 3RD STREET
Mailing Address - Street 2:
Mailing Address - City:HARDIN
Mailing Address - State:MT
Mailing Address - Zip Code:59034-1701
Mailing Address - Country:US
Mailing Address - Phone:406-665-1204
Mailing Address - Fax:406-665-4177
Practice Address - Street 1:215 W 3RD STREET
Practice Address - Street 2:
Practice Address - City:HARDIN
Practice Address - State:MT
Practice Address - Zip Code:59034-1701
Practice Address - Country:US
Practice Address - Phone:406-665-1204
Practice Address - Fax:406-665-4177
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-26
Last Update Date:2010-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT431152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT048-4185Medicaid
MT0152700001Medicare NSC
MT000T95943Medicare UPIN