MEDICARE: DR. JEFFREY PAUL GRAVIET 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	ODP-1021	ID

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1831148105
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JEFFREY PAUL GRAVIET O.D.

Provider Business Mailing Address
First Line	:	170 S SENECA SPRINGS WAY STE 100
Second Line	:
City	:	STAR
State	:	ID
Zip	:	83669-5938
Country	:	US
Telephone Number	:	208-898-4112
Fax Number	:

Provider Business Practice Location Address
First Line	:	170 S SENECA SPRINGS WAY
Second Line	:	STE 100
City	:	STAR
State	:	ID
Zip	:	83669-5938
Country	:	US
Telephone Number	:	208-898-4112
Fax Number	:

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

Provider Enumeration Date	:	05/06/2006
Last Update Date	:	09/17/2012

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