Healthcare Provider Details

I. General information

NPI: 1952415390
Provider Name (Legal Business Name): HULON HOUSTON PASS O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/19/2006
Last Update Date: 12/19/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

605 N MAIN ST
FORT STOCKTON TX
79735-5625
US

IV. Provider business mailing address

PO BOX 1568
FORT STOCKTON TX
79735-1568
US

V. Phone/Fax

Practice location:
  • Phone: 432-336-3662
  • Fax: 432-336-7806
Mailing address:
  • Phone: 432-336-3662
  • Fax: 432-336-7806

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number3081TG
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: