Provider Demographics
NPI:1841350584
Name:GRIMWOOD, MARY M (OD)
Entity type:Individual
Prefix:DR
First Name:MARY
Middle Name:M
Last Name:GRIMWOOD
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 1:141 N. WEBER RD.
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60490
Mailing Address - Country:US
Mailing Address - Phone:630-378-4342
Mailing Address - Fax:630-378-4147
Practice Address - Street 1:141 N. WEBER RD.
Practice Address - Street 2:
Practice Address - City:BOLINGBROOK
Practice Address - State:IL
Practice Address - Zip Code:60490
Practice Address - Country:US
Practice Address - Phone:630-378-4342
Practice Address - Fax:630-378-4147
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-11
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL46009349152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILMG1070971OtherDEA