Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 152W00000X | Optometrist | 3696TG | TX |
NPI | 1003908013 |
---|---|
Provider Name | Dr. Mark Raymond Tholen |
First Address | Dripping Springs, TX 78620-3402 |
Second Address | Dripping Springs, TX 78620-3402 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 28/09/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
T90854 | (02) | TX |