Provider Demographics
NPI:1447692793
Name:GRK, DEJANA (OD)
Entity type:Individual
Prefix:MISS
First Name:DEJANA
Middle Name:
Last Name:GRK
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 1:3701 WILSHIRE BLVD STE 600
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90010-2814
Mailing Address - Country:US
Mailing Address - Phone:323-361-3550
Mailing Address - Fax:
Practice Address - Street 1:1331 N 7TH ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85006
Practice Address - Country:US
Practice Address - Phone:602-222-2234
Practice Address - Fax:602-222-3025
Is Sole Proprietor?:No
Enumeration Date:2013-07-26
Last Update Date:2018-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT33832152WP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WP0200XEye and Vision Services ProvidersOptometristPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX112409104Medicaid
TX1861493140OtherGROUP NPI
TX1861493140OtherGROUP NPI