Provider Demographics
NPI:1942350756
Name:HUMPHREYS, GRANT R (OD)
Entity Type:Individual
Prefix:
First Name:GRANT
Middle Name:R
Last Name:HUMPHREYS
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 1:4341 TUDOR CENTRE DR
Mailing Address - Street 2:SUITE 200
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99508-5904
Mailing Address - Country:US
Mailing Address - Phone:907-729-8500
Mailing Address - Fax:
Practice Address - Street 1:4341 TUDOR CENTRE DR
Practice Address - Street 2:SUITE 200
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99508-5904
Practice Address - Country:US
Practice Address - Phone:907-729-8500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-12
Last Update Date:2014-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK144152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKOD01442Medicaid
AK150251Medicare ID - Type Unspecified
AK8EE752Medicare PIN
AKU68807Medicare UPIN