Provider Demographics
NPI:1801875521
Name:GRAVES, JOHN S (OD PC)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:S
Last Name:GRAVES
Suffix:
Gender:M
Credentials:OD PC
Other - Prefix:
Other - First Name:JOHN
Other - Middle Name:S
Other - Last Name:GRAVES
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OD PC
Mailing Address - Street 1:105 N GROVE
Mailing Address - Street 2:PO BOX 576
Mailing Address - City:STANDISH
Mailing Address - State:MI
Mailing Address - Zip Code:48658-0576
Mailing Address - Country:US
Mailing Address - Phone:989-846-4197
Mailing Address - Fax:989-846-4989
Practice Address - Street 1:105 N GROVE
Practice Address - Street 2:
Practice Address - City:STANDISH
Practice Address - State:MI
Practice Address - Zip Code:48658-0576
Practice Address - Country:US
Practice Address - Phone:989-846-4197
Practice Address - Fax:989-846-4989
Is Sole Proprietor?:No
Enumeration Date:2006-01-11
Last Update Date:2023-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901003143152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI900Z600100OtherBLUE CROSS BLUE SHIELD OF MICHIGAN
MI900Z600100OtherBLUE CROSS BLUE SHIELD OF MICHIGAN
MIMI4108Medicare PIN