Provider Demographics
NPI:1710362058
Name:KNOWLES, GRANT (OD)
Entity Type:Individual
Prefix:
First Name:GRANT
Middle Name:
Last Name:KNOWLES
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 1:506 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:OR
Mailing Address - Zip Code:97338-1915
Mailing Address - Country:US
Mailing Address - Phone:503-623-9233
Mailing Address - Fax:503-623-9233
Practice Address - Street 1:405 BOYD LN
Practice Address - Street 2:
Practice Address - City:MONMOUTH
Practice Address - State:OR
Practice Address - Zip Code:97361-1611
Practice Address - Country:US
Practice Address - Phone:503-838-1244
Practice Address - Fax:503-837-0313
Is Sole Proprietor?:No
Enumeration Date:2015-07-28
Last Update Date:2015-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR3614ATI152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist