Provider Demographics
NPI:1912064130
Name:DUVALL, BRUCE GRANGER (OD)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:GRANGER
Last Name:DUVALL
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 1:1095 E ARROW HWY
Mailing Address - Street 2:
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91786-5465
Mailing Address - Country:US
Mailing Address - Phone:909-981-5399
Mailing Address - Fax:
Practice Address - Street 1:1095 E ARROW HWY
Practice Address - Street 2:
Practice Address - City:UPLAND
Practice Address - State:CA
Practice Address - Zip Code:91786-5465
Practice Address - Country:US
Practice Address - Phone:909-981-5399
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-03
Last Update Date:2008-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA07694152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0076940Medicaid
CA03587OtherMEDICAL EYE SERVICE
CAT10579Medicare UPIN
CASD0076940Medicare PIN
CA03587OtherMEDICAL EYE SERVICE