Healthcare Provider Details

I. General information

NPI: 1972616134
Provider Name (Legal Business Name): RICHARD PHARUS JACKSON O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/15/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

216 W WASHINGTON ST
ANTHONY TX
79821-9304
US

IV. Provider business mailing address

216 W WASHINGTON ST
ANTHONY TX
79821-9304
US

V. Phone/Fax

Practice location:
  • Phone: 915-886-3005
  • Fax: 915-886-3005
Mailing address:
  • Phone: 915-886-3005
  • Fax: 915-886-3005

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number4023T
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: