Provider Demographics
NPI:1740241975
Name:GRAF, BOB H (OD)
Entity Type:Individual
Prefix:DR
First Name:BOB
Middle Name:H
Last Name:GRAF
Suffix:
Gender:M
Credentials:OD
Other - Prefix:DR
Other - First Name:ROBERT
Other - Middle Name:H
Other - Last Name:GRAF
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OD
Mailing Address - Street 1:2004 EDISON RD STE A
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46617-1712
Mailing Address - Country:US
Mailing Address - Phone:574-288-2400
Mailing Address - Fax:574-288-7132
Practice Address - Street 1:2004 EDISON RD STE A
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46617-1712
Practice Address - Country:US
Practice Address - Phone:574-288-2400
Practice Address - Fax:574-288-7132
Is Sole Proprietor?:No
Enumeration Date:2006-03-29
Last Update Date:2009-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18001516A152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100279420Medicaid
IN000000488802OtherBCBS ELK
IN000000539542OtherBCBS SOBEND
IN194030DMedicare PIN
IN100279420Medicaid