Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 152W00000X | Optometrist | 5817TG | TX |
N | 152WC0802X | Optomitrist - Corneal and Contact Lenses | 5817TG | TX |
N | 152WP0200X | Pediatric Optomitrist | 5817TG | TX |
N | 152WS0006X | Sports Vision | 5817TG | TX |
N | 152WV0400X | Optomitrist - Vision Therapist | 5817TG | TX |
N | 152WX0102X | Occupational Vision | 5817TG | TX |
NPI | 1134275761 |
---|---|
Provider Name | Dr. Terrisa Jo Drake |
First Address | San Antonio, TX 78227-1676 |
Second Address | San Antonio, TX 78227-1676 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 26/01/2007 |
Last Update Date | 19/02/2019 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1134275761 | (05) | TX |
488959ZUNK | MEDICARE GROUP MEMBER PROVIDER NUMBER (01) | TX |
U77329 | (02) | TX |