MEDICARE: DR. J GRADY ELLIOTT 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	1456	NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0112W	OTHER	NC	BCBS
2	0247000001	OTHER	NC	PALMETTO GBA
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1285774166
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. J GRADY ELLIOTT O.D.

Provider Business Mailing Address
First Line	:	3111 MAPLEWOOD AVE
Second Line	:	SUITE 103
City	:	WINSTON SALEM
State	:	NC
Zip	:	27103-3906
Country	:	US
Telephone Number	:	336-765-8130
Fax Number	:	336-765-6403

Provider Business Practice Location Address
First Line	:	3111 MAPLEWOOD AVE
Second Line	:	SUITE 103
City	:	WINSTON SALEM
State	:	NC
Zip	:	27103-3906
Country	:	US
Telephone Number	:	336-765-8130
Fax Number	:	336-765-6403

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

Provider Enumeration Date	:	02/08/2007
Last Update Date	:	04/13/2011

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