Provider Demographics
NPI:1619069796
Name:RUBESH, GRANT (OD)
Entity Type:Individual
Prefix:
First Name:GRANT
Middle Name:
Last Name:RUBESH
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 1:11103 WEST AVE
Mailing Address - Street 2:STE 6
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78213-1370
Mailing Address - Country:US
Mailing Address - Phone:210-524-6663
Mailing Address - Fax:210-524-6587
Practice Address - Street 1:516 E LEWIS AND CLARK PKWY
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47129-1700
Practice Address - Country:US
Practice Address - Phone:812-282-2020
Practice Address - Fax:812-288-2807
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18003417A152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist