Healthcare Provider Details

I. General information

NPI: 1912064130
Provider Name (Legal Business Name): BRUCE GRANGER DUVALL O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/03/2007
Last Update Date: 05/13/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1095 E ARROW HWY
UPLAND CA
91786-5465
US

IV. Provider business mailing address

1095 E ARROW HWY
UPLAND CA
91786-5465
US

V. Phone/Fax

Practice location:
  • Phone: 909-981-5399
  • Fax:
Mailing address:
  • Phone: 909-981-5399
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number07694
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: