Healthcare Provider Details

I. General information

NPI: 1154435600
Provider Name (Legal Business Name): AGNES L TRAN O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/19/2006
Last Update Date: 04/25/2022
Certification Date: 04/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

520 W UNIVERSITY ST STE C
SPRINGFIELD MO
65807-1964
US

IV. Provider business mailing address

520 W UNIVERSITY ST STE C
SPRINGFIELD MO
65807-1964
US

V. Phone/Fax

Practice location:
  • Phone: 417-831-8222
  • Fax: 877-417-7310
Mailing address:
  • Phone: 417-831-8222
  • Fax: 877-417-7310

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2000166242
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: