Provider Demographics
NPI:1891066023
Name:GRANDE, BERTRAM J (RO)
Entity Type:Individual
Prefix:MR
First Name:BERTRAM
Middle Name:J
Last Name:GRANDE
Suffix:
Gender:M
Credentials:RO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:734 NEWPORT AVE
Mailing Address - Street 2:
Mailing Address - City:ATTLEBORO
Mailing Address - State:MA
Mailing Address - Zip Code:02703-5935
Mailing Address - Country:US
Mailing Address - Phone:508-761-6100
Mailing Address - Fax:508-761-5500
Practice Address - Street 1:734 NEWPORT AVE
Practice Address - Street 2:
Practice Address - City:ATTLEBORO
Practice Address - State:MA
Practice Address - Zip Code:02703-5935
Practice Address - Country:US
Practice Address - Phone:508-761-6100
Practice Address - Fax:508-761-5500
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-19
Last Update Date:2012-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA4800156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician