Healthcare Provider Details

I. General information

NPI: 1194706861
Provider Name (Legal Business Name): IVAN BRUCE BANK O.D. ,F.A.A.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/09/2005
Last Update Date: 01/10/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8611 HILLCREST AVE STE. 140
DALLAS TX
75225-4207
US

IV. Provider business mailing address

8611 HILLCREST AVE STE. 140
DALLAS TX
75225-4207
US

V. Phone/Fax

Practice location:
  • Phone: 214-739-8611
  • Fax: 214-739-8612
Mailing address:
  • Phone: 214-739-8611
  • Fax: 214-739-8612

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number930-108T
License Number StateLA
# 2
Primary TaxonomyY
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number03313TG
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: