MEDICARE: DR. JEFFREY NELSON LEGRANDE 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	152W00000X	Optometrist	6528T	TX

General Provider Information

NPI Number	:	1972594927
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JEFFREY NELSON LEGRANDE O.D.

Provider Business Mailing Address
First Line	:	8202 N LOOP 1604 W
Second Line	:	STE 105
City	:	SAN ANTONIO
State	:	TX
Zip	:	78249-2897
Country	:	US
Telephone Number	:	210-691-4733
Fax Number	:	210-691-3322

Provider Business Practice Location Address
First Line	:	8202 N LOOP 1604 W STE 105
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78249-2898
Country	:	US
Telephone Number	:	210-691-4733
Fax Number	:	210-424-9156

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

Provider Enumeration Date	:	10/31/2005
Last Update Date	:	04/05/2014

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