GRAVES, LYNDON (OD)

Provider Demographics

• NPI: 1205886736
• Name: GRAVES, LYNDON (OD)
• Entity type: Individual
• First Name: LYNDON
• Last Name: GRAVES
• Gender: M
• Credentials: OD
• Mailing Address - Street 1: 9239 W CENTER RD
• Mailing Address - Street 2: STE 103
• Mailing Address - City: OMAHA
• Mailing Address - State: NE
• Mailing Address - Zip Code: 68124-1900
• Mailing Address - Country: US
• Mailing Address - Phone: 402-898-3232
• Mailing Address - Fax: 402-898-3234
• Practice Address - Street 1: 9239 W CENTER RD
• Practice Address - Street 2: SUITE 103
• Practice Address - City: OMAHA
• Practice Address - State: NE
• Practice Address - Zip Code: 68124-1900
• Practice Address - Country: US
• Practice Address - Phone: 402-898-3232
• Practice Address - Fax: 402-898-3234
• Is Sole Proprietor?: No
• Enumeration Date: 2006-05-12
• Last Update Date: 2015-04-30

Provider Licenses

State	License ID	Taxonomies
VA	0601800388	152W00000X
NE	998	152W00000X, 152W00000X
IA	15201890	152W00000X
CO	2277	152W00000X
OR	2967T	152W00000X
WA	OD00003880	152W00000X
UT	5659180-9934	152W00000X
LA	1387	152W00000X
TN	OD0000002562	152W00000X
KY	1791	152W00000X

Provider Taxonomies

Primary?	Code	Type	Classification	Specialization
Yes	152W00000X	Eye and Vision Services Providers	Optometrist

Provider Identifiers

State	Identifier ID	ID Type	Issuer
IA	38550	Other	BLUECROSS BLUESHIELD
WA	2029544	Medicaid
LA	1473839	Medicaid
UT	U000075637	Medicare PIN
	P00096408	Medicare PIN
IA	IB2387001	Medicare PIN
IA	38550	Other	BLUECROSS BLUESHIELD
IA	IB2388001	Medicare PIN
WA	G8907765	Medicare PIN
NE	NA2057002	Medicare PIN
NE	P00043289	Medicare PIN
	P00176089	Medicare PIN
	P00165710	Medicare PIN
IA	P00822818	Medicare PIN
DC	156377ZD26	Medicare PIN
WA	2029544	Medicaid
NE	NA2058002	Medicare PIN
	P00303245	Medicare PIN
WA	G8907714	Medicare PIN
LA	4R158DW67	Medicare PIN
NE	NA2059002	Medicare PIN
VA	VV2517A	Medicare PIN
IA	IB2383001	Medicare PIN
OK	OHCA-2002-23	Medicaid
NE	P00043289	Medicare PIN
	P00176089	Medicare PIN
IA	IB2384001	Medicare PIN
IA	38550	Other	BLUECROSS BLUESHIELD
NE	267856	Medicare ID - Type Unspecified
UT	5773502	Medicare ID - Type Unspecified
UT	000066929	Medicare PIN
LA	4B307	Medicare ID - Type Unspecified
WA	G8807709	Medicare PIN
NE	NA1412001	Medicare PIN
IA	IB2387001	Medicare PIN
VA	00Y007L01	Medicare PIN
IA	IB1603001	Medicare PIN
NE	NA1410001	Medicare PIN
IA	IB2383001	Medicare PIN
	P00303245	Medicare PIN
CO	43872379	Medicaid