MEDICARE: GREGG DUISTERMARS 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	7368TG	TX

General Provider Information

NPI Number	:	1376696427
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GREGG DUISTERMARS O.D.

Provider Business Mailing Address
First Line	:	1201 MEDICAL PLAZA CT
Second Line	:
City	:	GRANBURY
State	:	TX
Zip	:	76048-5684
Country	:	US
Telephone Number	:	817-279-9044
Fax Number	:	817-573-6234

Provider Business Practice Location Address
First Line	:	1201 MEDICAL PLAZA CT
Second Line	:
City	:	GRANBURY
State	:	TX
Zip	:	76048-5684
Country	:	US
Telephone Number	:	817-279-9044
Fax Number	:	817-573-6234

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

Provider Enumeration Date	:	01/20/2007
Last Update Date	:	08/20/2013

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