Provider Demographics
NPI:1891739066
Name:GRADEN, TY M (OD)
Entity Type:Individual
Prefix:DR
First Name:TY
Middle Name:M
Last Name:GRADEN
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 1:405 S MARKET ST
Mailing Address - Street 2:PRIMARY EYE CARE CENTER PC
Mailing Address - City:ELIZABETHTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:17022
Mailing Address - Country:US
Mailing Address - Phone:717-367-1883
Mailing Address - Fax:717-367-1884
Practice Address - Street 1:405 S MARKET ST
Practice Address - Street 2:PRIMARY EYE CARE CENTER PC
Practice Address - City:ELIZABETHTOWN
Practice Address - State:PA
Practice Address - Zip Code:17022
Practice Address - Country:US
Practice Address - Phone:717-367-1883
Practice Address - Fax:717-367-1884
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG001522152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA563405Medicare ID - Type Unspecified
T91712Medicare UPIN