Healthcare Provider Details

I. General information

NPI: 1992275077
Provider Name (Legal Business Name): IDIL OVUTMEN OD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/30/2018
Last Update Date: 11/30/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1937 TEXAS AVE S
COLLEGE STATION TX
77840-3913
US

IV. Provider business mailing address

5615 RIVERSTONE CROSSING DR
SUGAR LAND TX
77479-4869
US

V. Phone/Fax

Practice location:
  • Phone: 979-213-5104
  • Fax:
Mailing address:
  • Phone: 832-344-7792
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number9473
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: