Healthcare Provider Details

I. General information

NPI: 1386252617
Provider Name (Legal Business Name): CANDRA' Y HEPBURN OD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/22/2020
Last Update Date: 03/10/2024
Certification Date: 03/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

780 ROAD TO SIX FLAGS ST E STE 224
ARLINGTON TX
76011-8406
US

IV. Provider business mailing address

780 ROAD TO SIX FLAGS ST E STE 224
ARLINGTON TX
76011-8406
US

V. Phone/Fax

Practice location:
  • Phone: 817-505-1500
  • Fax:
Mailing address:
  • Phone: 817-505-1500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number10062
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: