Healthcare Provider Details

I. General information

NPI: 1760710776
Provider Name (Legal Business Name): MICHAEL B. GRINDSTAFF, O.D., P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/02/2009
Last Update Date: 06/14/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1482 S BRYANT AVE
EDMOND OK
73034-5752
US

IV. Provider business mailing address

1482 S BRYANT AVE
EDMOND OK
73034-5752
US

V. Phone/Fax

Practice location:
  • Phone: 405-715-3937
  • Fax: 405-715-3938
Mailing address:
  • Phone: 405-715-3937
  • Fax: 405-715-3938

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number
License Number State

VIII. Authorized Official

Name: DR. MICHAEL B. GRINDSTAFF
Title or Position: OWNER
Credential: O.D.
Phone: 405-715-3937