Healthcare Provider Details

I. General information

NPI: 1811200389
Provider Name (Legal Business Name): MINDI GREENE KAVANAUGH OD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MINDI MEIER

II. Dates (important events)

Enumeration Date: 07/26/2010
Last Update Date: 10/03/2023
Certification Date: 10/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

725 E VILLA MARIA RD STE 1500
BRYAN TX
77802-5345
US

IV. Provider business mailing address

725 E VILLA MARIA RD STE 1500
BRYAN TX
77802-5345
US

V. Phone/Fax

Practice location:
  • Phone: 979-775-4900
  • Fax: 979-775-4949
Mailing address:
  • Phone: 979-775-4900
  • Fax: 979-775-4949

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152WP0200X
TaxonomyPediatric Optometrist
License Number5828T
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number5828T
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: