Provider Demographics
NPI:1942964093
Name:GRANT, DORA (OPTICIAN)
Entity Type:Individual
Prefix:MRS
First Name:DORA
Middle Name:
Last Name:GRANT
Suffix:
Gender:F
Credentials:OPTICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1320 N PARKER AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46201-1202
Mailing Address - Country:US
Mailing Address - Phone:317-345-9396
Mailing Address - Fax:
Practice Address - Street 1:8532 CASTLETON CORNER DR STE 23
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46250-3812
Practice Address - Country:US
Practice Address - Phone:317-829-6047
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-25
Last Update Date:2021-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician