Provider Demographics
NPI:1952364465
Name:AGRANOV, DOUGLAS P (OD)
Entity Type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:P
Last Name:AGRANOV
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 1:87 GRANDVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:WATERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06708-2514
Mailing Address - Country:US
Mailing Address - Phone:203-574-2020
Mailing Address - Fax:203-596-2230
Practice Address - Street 1:749 BOSTON POST RD
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:CT
Practice Address - Zip Code:06443-3044
Practice Address - Country:US
Practice Address - Phone:203-245-1492
Practice Address - Fax:203-245-9002
Is Sole Proprietor?:No
Enumeration Date:2006-04-07
Last Update Date:2010-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000703152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004023701Medicaid
CT410000887Medicare ID - Type Unspecified
CTT22510Medicare UPIN