Provider Demographics
NPI:1790723609
Name:GRANDISON, REGINALD DEAN (OD)
Entity Type:Individual
Prefix:DR
First Name:REGINALD
Middle Name:DEAN
Last Name:GRANDISON
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 1:23832 SOUTHFIELD RD
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48075-8017
Mailing Address - Country:US
Mailing Address - Phone:248-443-8089
Mailing Address - Fax:313-865-1867
Practice Address - Street 1:23832 SOUTHFIELD RD
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-8017
Practice Address - Country:US
Practice Address - Phone:248-443-8089
Practice Address - Fax:313-865-1867
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-03
Last Update Date:2008-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901003700152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0P32520Medicare PIN
MIU71473Medicare UPIN