Provider Demographics
NPI:1205998234
Name:GRAVES, JEANINE ELIZABETH (OD)
Entity type:Individual
Prefix:DR
First Name:JEANINE
Middle Name:ELIZABETH
Last Name:GRAVES
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22122 BRADFORD GREEN SQUARE
Mailing Address - Street 2:
Mailing Address - City:CARY
Mailing Address - State:NC
Mailing Address - Zip Code:27519
Mailing Address - Country:US
Mailing Address - Phone:201-796-2036
Mailing Address - Fax:
Practice Address - Street 1:230 E. RIDGEWOOD AVE
Practice Address - Street 2:
Practice Address - City:PARAMUS
Practice Address - State:NJ
Practice Address - Zip Code:07652
Practice Address - Country:US
Practice Address - Phone:201-796-2036
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-15
Last Update Date:2024-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ27 OA00511200152W00000X
NY005115152W00000X
WI21335-875152W00000X
OHOPT.007117152W00000X
FLTPOP94152W00000X
MN3854152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJU29686Medicare UPIN
NJ4658390001Medicare NSC
NJGR753922Medicare ID - Type UnspecifiedGROUP NUMBER