Healthcare Provider Details

I. General information

NPI: 1285174102
Provider Name (Legal Business Name): ANNA OKULIST
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/24/2017
Last Update Date: 08/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1011 W 5TH ST STE 120
AUSTIN TX
78703
US

IV. Provider business mailing address

1011 W 5TH ST STE 120
AUSTIN TX
78703-5363
US

V. Phone/Fax

Practice location:
  • Phone: 737-990-4135
  • Fax:
Mailing address:
  • Phone: 737-990-4135
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number102545
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number35092
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: