Healthcare Provider Details

I. General information

NPI: 1912182650
Provider Name (Legal Business Name): JERRY K YEANG
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/31/2007
Last Update Date: 11/09/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6500 S PADRE ISLAND DR STE 17
CORPUS CHRISTI TX
78412-4055
US

IV. Provider business mailing address

6500 S PADRE ISLAND DR STE 17
CORPUS CHRISTI TX
78412-4055
US

V. Phone/Fax

Practice location:
  • Phone: 361-993-3388
  • Fax: 361-993-3388
Mailing address:
  • Phone: 361-993-3388
  • Fax: 361-993-3388

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number3407TG
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: