Provider Demographics
NPI:1831148105
Name:GRAVIET, JEFFREY PAUL (OD)
Entity type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:PAUL
Last Name:GRAVIET
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 1:170 S SENECA SPRINGS WAY STE 100
Mailing Address - Street 2:
Mailing Address - City:STAR
Mailing Address - State:ID
Mailing Address - Zip Code:83669-5938
Mailing Address - Country:US
Mailing Address - Phone:208-898-4112
Mailing Address - Fax:
Practice Address - Street 1:170 S SENECA SPRINGS WAY
Practice Address - Street 2:STE 100
Practice Address - City:STAR
Practice Address - State:ID
Practice Address - Zip Code:83669-5938
Practice Address - Country:US
Practice Address - Phone:208-898-4112
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-06
Last Update Date:2012-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDODP-1021152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID807258500Medicaid
IDV02626Medicare UPIN
ID807258500Medicaid