Provider Demographics
NPI:1245886837
Name:GRAVLEE, JONATHAN (OD)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:
Last Name:GRAVLEE
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 1:8614 WESTWOOD CENTER DR FL 9
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22182-2442
Mailing Address - Country:US
Mailing Address - Phone:703-847-8899
Mailing Address - Fax:
Practice Address - Street 1:1686 MONTGOMERY HWY
Practice Address - Street 2:
Practice Address - City:HOOVER
Practice Address - State:AL
Practice Address - Zip Code:35216-4906
Practice Address - Country:US
Practice Address - Phone:205-979-2020
Practice Address - Fax:205-978-6487
Is Sole Proprietor?:No
Enumeration Date:2019-08-10
Last Update Date:2024-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALS-E25-TA-B50152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist