Provider Demographics
NPI:1679922058
Name:GRANT, EDWIN (OD)
Entity type:Individual
Prefix:DR
First Name:EDWIN
Middle Name:
Last Name:GRANT
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 1:3733 PARK EAST DR STE 104
Mailing Address - Street 2:
Mailing Address - City:BEACHWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:44122-4334
Mailing Address - Country:US
Mailing Address - Phone:216-839-0200
Mailing Address - Fax:
Practice Address - Street 1:3733 PARK EAST DR STE 104
Practice Address - Street 2:
Practice Address - City:BEACHWOOD
Practice Address - State:OH
Practice Address - Zip Code:44122-4334
Practice Address - Country:US
Practice Address - Phone:216-839-0200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-07
Last Update Date:2016-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH6457152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist