Provider Demographics
NPI:1922165521
Name:GRANT, DRUSILLA HASKINS (OD)
Entity Type:Individual
Prefix:DR
First Name:DRUSILLA
Middle Name:HASKINS
Last Name:GRANT
Suffix:
Gender:F
Credentials:OD
Other - Prefix:MRS
Other - First Name:DRUSILLA
Other - Middle Name:GRANT
Other - Last Name:WEATHERBY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:OD
Mailing Address - Street 1:1520 PORTAGE TRAIL
Mailing Address - Street 2:SUITE 2
Mailing Address - City:CUYAHOGA FALLS
Mailing Address - State:OH
Mailing Address - Zip Code:44223-2121
Mailing Address - Country:US
Mailing Address - Phone:330-923-9951
Mailing Address - Fax:330-923-6419
Practice Address - Street 1:1520 PORTAGE TRAIL
Practice Address - Street 2:SUITE 2
Practice Address - City:CUYAHOGA FALLS
Practice Address - State:OH
Practice Address - Zip Code:44223-2121
Practice Address - Country:US
Practice Address - Phone:330-923-9951
Practice Address - Fax:330-923-6419
Is Sole Proprietor?:No
Enumeration Date:2007-01-02
Last Update Date:2008-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3533 T464152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0505842Medicare PIN
OHT47436Medicare UPIN