Provider Demographics
NPI:1558321208
Name:GRANT, MARY ALYSTER (OD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:ALYSTER
Last Name:GRANT
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:2755 E DESERT INN RD STE 270
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89121-3690
Mailing Address - Country:US
Mailing Address - Phone:702-836-3600
Mailing Address - Fax:702-836-3606
Practice Address - Street 1:2755 E DESERT INN RD
Practice Address - Street 2:#700
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89121-3690
Practice Address - Country:US
Practice Address - Phone:702-836-3600
Practice Address - Fax:702-836-3606
Is Sole Proprietor?:No
Enumeration Date:2006-03-26
Last Update Date:2018-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV385152WP0200X, 152WV0400X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WP0200XEye and Vision Services ProvidersOptometristPediatrics
No152WV0400XEye and Vision Services ProvidersOptometristVision Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV002502100Medicaid