MEDICARE: MINI JOHN OD PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	6184TG	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	6184TG	OTHER	TX	TEXAS OPTOMETRY LICENSE

General Provider Information

NPI Number	:	1043522816
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MINI JOHN OD PLLC

Provider Business Mailing Address
First Line	:	2755 TEXAS PKWY
Second Line	:
City	:	MISSOURI CITY
State	:	TX
Zip	:	77489-5105
Country	:	US
Telephone Number	:	281-300-2109
Fax Number	:	713-995-0548

Provider Business Practice Location Address
First Line	:	2755 TEXAS PKWY
Second Line	:
City	:	MISSOURI CITY
State	:	TX
Zip	:	77489-5105
Country	:	US
Telephone Number	:	281-300-2109
Fax Number	:	713-995-0548

Authorized Official
Title or Position	:	OWNER/OD
Name	:	MINI JOHN
Credential	:	OD
Telephone Number	:	281-300-2109

Provider Enumeration Date	:	07/09/2010
Last Update Date	:	01/26/2012

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Directions to “MINI JOHN OD PLLC ” Practice Location

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