1326149717 NPI number — DR. GAIL JOHNSON GRAU O.D.

Table of content: DR. GAIL JOHNSON GRAU O.D. (NPI 1326149717)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1326149717 NPI number — DR. GAIL JOHNSON GRAU O.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GRAU
Provider First Name:
GAIL
Provider Middle Name:
JOHNSON
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
O.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1326149717
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/15/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
699 MCBROOM ST NW
Provider Second Line Business Mailing Address:
SUITE A
Provider Business Mailing Address City Name:
ABINGDON
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
24210-2511
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
276-628-1143
Provider Business Mailing Address Fax Number:
276-628-9522

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
699 MCBROOM ST NW
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
ABINGDON
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
24210-2511
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
276-628-1143
Provider Business Practice Location Address Fax Number:
276-628-9522
Provider Enumeration Date:
09/26/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  0618000166 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 009205144 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: CA3685 . This is a "PALMETTO GBA RAILROAD MEDIARE" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".