Basic Information
| Provider Information | |||||||||
| NPI: | 1952364465 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | AGRANOV | ||||||||
| FirstName: | DOUGLAS | ||||||||
| MiddleName: | P | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | O.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 87 GRANDVIEW AVE | ||||||||
| Address2: | |||||||||
| City: | WATERBURY | ||||||||
| State: | CT | ||||||||
| PostalCode: | 067082514 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2035742020 | ||||||||
| FaxNumber: | 2035962230 | ||||||||
| Practice Location | |||||||||
| Address1: | 749 BOSTON POST RD | ||||||||
| Address2: | |||||||||
| City: | MADISON | ||||||||
| State: | CT | ||||||||
| PostalCode: | 064433044 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2032451492 | ||||||||
| FaxNumber: | 2032459002 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/07/2006 | ||||||||
| LastUpdateDate: | 02/12/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 000703 | CT | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 004023701 | 05 | CT | MEDICAID |