Healthcare Provider Details

I. General information

NPI: 1326326091
Provider Name (Legal Business Name): DAVID GRISHAM OD, MS, FAAO,FCOVD-A
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: JOHN DAVID GRISHAM OD,MS,FAAO,FCOVA-A

II. Dates (important events)

Enumeration Date: 07/29/2011
Last Update Date: 07/29/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

615 B ST SUITE 2
SAN RAFAEL CA
94901-3805
US

IV. Provider business mailing address

615 B ST SUITE 2
SAN RAFAEL CA
94901-3805
US

V. Phone/Fax

Practice location:
  • Phone: 415-459-2020
  • Fax: 415-459-2021
Mailing address:
  • Phone: 415-459-2020
  • Fax: 415-459-2021

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152WL0500X
TaxonomyLow Vision Rehabilitation Optometrist
License Number5110
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code152WP0200X
TaxonomyPediatric Optometrist
License Number5110
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code152WS0006X
TaxonomySports Vision Optometrist
License Number5110
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code152WV0400X
TaxonomyVision Therapy Optometrist
License Number5110
License Number StateCA
# 5
Primary TaxonomyN
Taxonomy Code152WX0102X
TaxonomyOccupational Vision Optometrist
License Number5110
License Number StateCA
# 6
Primary TaxonomyN
Taxonomy Code156FX1100X
TaxonomyOphthalmic Technician/Technologist
License Number5110
License Number StateCA
# 7
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number5110
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: