Provider Demographics
NPI:1639280951
Name:GRILL, ROBERT B (OD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:B
Last Name:GRILL
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 1:844 SHOSHONE ST E
Mailing Address - Street 2:
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83301-6336
Mailing Address - Country:US
Mailing Address - Phone:208-734-9800
Mailing Address - Fax:208-734-9433
Practice Address - Street 1:844 SHOSHONE ST E
Practice Address - Street 2:
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-6336
Practice Address - Country:US
Practice Address - Phone:208-734-9800
Practice Address - Fax:208-734-9433
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2010-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDODP0628152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID002457900Medicaid
1591567Medicare ID - Type Unspecified
ID002457900Medicaid
410010799Medicare ID - Type UnspecifiedRAILROAD