Provider Demographics
NPI:1871687640
Name:GRAHAM, GLENN NICOLAS (OD)
Entity Type:Individual
Prefix:DR
First Name:GLENN
Middle Name:NICOLAS
Last Name:GRAHAM
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 1:1245 BROAD ST
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93401
Mailing Address - Country:US
Mailing Address - Phone:805-542-0700
Mailing Address - Fax:805-784-9309
Practice Address - Street 1:1245 BROAD ST
Practice Address - Street 2:
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401
Practice Address - Country:US
Practice Address - Phone:805-542-0700
Practice Address - Fax:805-784-9309
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2014-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA7203T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
U29801Medicare UPIN
CAWY146Medicare ID - Type Unspecified
CACE549ZMedicare PIN