MEDICARE: DR. MARY ALYSTER GRANT O.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152WP0200X	Pediatric Optometrist	385	NV
2	152WV0400X	Vision Therapy Optometrist	385	NV
3	152W00000X	Optometrist	385	NV

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1558321208
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARY ALYSTER GRANT O.D.

Provider Business Mailing Address
First Line	:	2755 E DESERT INN RD STE 270
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89121-3690
Country	:	US
Telephone Number	:	702-836-3600
Fax Number	:	702-836-3606

Provider Business Practice Location Address
First Line	:	2755 E DESERT INN RD
Second Line	:	#700
City	:	LAS VEGAS
State	:	NV
Zip	:	89121-3690
Country	:	US
Telephone Number	:	702-836-3600
Fax Number	:	702-836-3606

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/26/2006
Last Update Date	:	02/15/2018

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