Provider Demographics
NPI:1932155827
Name:GRANGE, THOMAS W (OD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:W
Last Name:GRANGE
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 1:1103 GALVIN RD S
Mailing Address - Street 2:
Mailing Address - City:BELLEVUE
Mailing Address - State:NE
Mailing Address - Zip Code:68005-3002
Mailing Address - Country:US
Mailing Address - Phone:402-292-6514
Mailing Address - Fax:
Practice Address - Street 1:1103 GALVIN RD S
Practice Address - Street 2:SUITE H
Practice Address - City:BELLEVUE
Practice Address - State:NE
Practice Address - Zip Code:68005-3002
Practice Address - Country:US
Practice Address - Phone:402-292-6514
Practice Address - Fax:402-292-7122
Is Sole Proprietor?:No
Enumeration Date:2006-05-25
Last Update Date:2010-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE915152W00000X
IA01937152W00000X
MN2081152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE265486Medicare ID - Type Unspecified
T74900Medicare UPIN