MEDICARE: DR. CAROLYN K KHA OD

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	6592TG	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	6592TG	OTHER	TX	TX OPTOMETRY BOARD
2	90136629	OTHER	TX	DPS REGISTRATION

General Provider Information

NPI Number	:	1114919677
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CAROLYN K KHA OD

Provider Business Mailing Address
First Line	:	4927 LAKE RIDGE PKWY
Second Line	:	SUITE NUMBER 160
City	:	GRAND PRAIRIE
State	:	TX
Zip	:	75052-3073
Country	:	US
Telephone Number	:	972-641-5900
Fax Number	:	972-641-5903

Provider Business Practice Location Address
First Line	:	4927 LAKE RIDGE PKWY
Second Line	:	SUITE NUMBER 160
City	:	GRAND PRAIRIE
State	:	TX
Zip	:	75052-3073
Country	:	US
Telephone Number	:	972-641-5900
Fax Number	:	972-641-5903

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/19/2005
Last Update Date	:	03/07/2023

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