Provider Demographics
NPI:1922386564
Name:GRANGER, GARY J (OD)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:J
Last Name:GRANGER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:107 CENTRE SARCELLE BLVD.
Mailing Address - Street 2:SUITE 704
Mailing Address - City:YOUNGSVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70592-6193
Mailing Address - Country:US
Mailing Address - Phone:337-451-4511
Mailing Address - Fax:337-857-6044
Practice Address - Street 1:107 CENTRE SARCELLE BLVD.
Practice Address - Street 2:SUITE 704
Practice Address - City:YOUNGSVILLE
Practice Address - State:LA
Practice Address - Zip Code:70592-6193
Practice Address - Country:US
Practice Address - Phone:337-451-4511
Practice Address - Fax:337-857-6044
Is Sole Proprietor?:No
Enumeration Date:2011-08-01
Last Update Date:2014-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1611-644T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2167626Medicaid
LA5B107Medicare UPIN