Provider Demographics
NPI:1457432221
Name:VORSTER, GRANT (OD)
Entity Type:Individual
Prefix:DR
First Name:GRANT
Middle Name:
Last Name:VORSTER
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 1:81833 DR CARREON BLVD
Mailing Address - Street 2:SUITE 5
Mailing Address - City:INDIO
Mailing Address - State:CA
Mailing Address - Zip Code:92201-0602
Mailing Address - Country:US
Mailing Address - Phone:760-863-2241
Mailing Address - Fax:760-863-1919
Practice Address - Street 1:81833 DR CARREON BLVD
Practice Address - Street 2:SUITE 5
Practice Address - City:INDIO
Practice Address - State:CA
Practice Address - Zip Code:92201-0602
Practice Address - Country:US
Practice Address - Phone:760-863-2241
Practice Address - Fax:760-863-1919
Is Sole Proprietor?:No
Enumeration Date:2006-10-18
Last Update Date:2014-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA12440T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0124400Medicaid
CASD0124400Medicaid
SD0124400Medicare ID - Type Unspecified