Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 152W00000X | Optometrist | 2286TG | TX |
N | 152WC0802X | Optomitrist - Corneal and Contact Lenses | 2286TG | TX |
N | 152WP0200X | Pediatric Optomitrist | 2286TG | TX |
NPI | 1245276443 |
---|---|
Provider Name | Dr. Bob Joe |
First Address | Austin, TX 78757-8040 |
Second Address | Austin, TX 78757-8040 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 22/06/2006 |
Last Update Date | 04/03/2008 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
81662Q | BCBS UPIN (01) | TX |
T14055 | (02) | TX |