Provider Demographics
NPI:1902910573
Name:GRIMES, AMY LYN (OD)
Entity Type:Individual
Prefix:DR
First Name:AMY
Middle Name:LYN
Last Name:GRIMES
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:784 W. ANNANDALE WAY
Mailing Address - Street 2:
Mailing Address - City:ORO VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:85737-6955
Mailing Address - Country:US
Mailing Address - Phone:520-229-0160
Mailing Address - Fax:520-838-3656
Practice Address - Street 1:3601 S. 6TH AVE
Practice Address - Street 2:(2-112A)
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85723
Practice Address - Country:US
Practice Address - Phone:520-792-1450
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1005152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ886509Medicaid
AZ82468Medicare ID - Type Unspecified
AZ886509Medicaid