Provider Demographics
NPI:1548746449
Name:GRAVES, PATRICK WILLIAM (OD)
Entity Type:Individual
Prefix:DR
First Name:PATRICK
Middle Name:WILLIAM
Last Name:GRAVES
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 1:476 WAVERLY DR
Mailing Address - Street 2:
Mailing Address - City:BENTON HARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:49022-6551
Mailing Address - Country:US
Mailing Address - Phone:269-930-0985
Mailing Address - Fax:
Practice Address - Street 1:215 E UNIVERSITY DR STE 150
Practice Address - Street 2:
Practice Address - City:GRANGER
Practice Address - State:IN
Practice Address - Zip Code:46530-4026
Practice Address - Country:US
Practice Address - Phone:574-271-7408
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-13
Last Update Date:2020-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18004121A152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist