Healthcare Provider Details

I. General information

NPI: 1013965409
Provider Name (Legal Business Name): GRACE LEA YU DUMAYAS-BOOTH O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: DR. GRACE LEA DEWARS

II. Dates (important events)

Enumeration Date: 05/05/2006
Last Update Date: 06/18/2021
Certification Date: 06/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

LANDSTUHL REGIONAL MEDICAL CENTER WIESBADEN HEALTH CLINIC UNIT 29623
APO AE
09096
DE

IV. Provider business mailing address

4430 MISSOURI AVE # 1263
FORT LEONARD WOOD MO
65473-9098
US

V. Phone/Fax

Practice location:
  • Phone: 011496117057307
  • Fax: 011496117055984
Mailing address:
  • Phone: 573-596-0048
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number0618002700
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOEG 001649
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: