Provider Demographics
NPI:1568542926
Name:GREBER, RANDOLPH J (OD, MS, FAAO)
Entity Type:Individual
Prefix:DR
First Name:RANDOLPH
Middle Name:J
Last Name:GREBER
Suffix:
Gender:M
Credentials:OD, MS, FAAO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6001 LARUE ST
Mailing Address - Street 2:
Mailing Address - City:HARRISBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17112-1743
Mailing Address - Country:US
Mailing Address - Phone:717-545-5070
Mailing Address - Fax:717-545-5470
Practice Address - Street 1:6001 LARUE ST
Practice Address - Street 2:
Practice Address - City:HARRISBURG
Practice Address - State:PA
Practice Address - Zip Code:17112-1743
Practice Address - Country:US
Practice Address - Phone:717-545-5070
Practice Address - Fax:717-545-5470
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPC001822101YM0800X
PAOEG000049152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Not Answered152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAT29620Medicare UPIN
PA148286Medicare ID - Type Unspecified