Provider Demographics
NPI:1851372155
Name:DE GRASSE, JANE ELIZABETH (OD)
Entity Type:Individual
Prefix:
First Name:JANE
Middle Name:ELIZABETH
Last Name:DE GRASSE
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 MERCEDES ST
Mailing Address - Street 2:
Mailing Address - City:BENBROOK
Mailing Address - State:TX
Mailing Address - Zip Code:76126-2593
Mailing Address - Country:US
Mailing Address - Phone:817-249-4078
Mailing Address - Fax:817-249-4094
Practice Address - Street 1:300 MERCEDES ST
Practice Address - Street 2:
Practice Address - City:BENBROOK
Practice Address - State:TX
Practice Address - Zip Code:76126-2593
Practice Address - Country:US
Practice Address - Phone:817-249-4078
Practice Address - Fax:817-249-4094
Is Sole Proprietor?:No
Enumeration Date:2005-11-14
Last Update Date:2014-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX5514TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXU66629Medicare UPIN
TX8D7079Medicare ID - Type Unspecified