Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 152W00000X | Optometrist | 3472TG | TX |
NPI | 1003917030 |
---|---|
Provider Name | Edward L Grimes |
First Address | San Angelo, TX 76902-7200 |
Second Address | San Angelo, TX 76901-5611 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 25/09/2006 |
Last Update Date | 13/09/2010 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
3472TG | (02) | TX |
82781Q | BCBS (01) | TX |