Healthcare Provider Details

I. General information

NPI: 1568568095
Provider Name (Legal Business Name): DIPAK MASTER O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/15/2006
Last Update Date: 06/01/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1235 WILLOWDALE LN
IRVING TX
75063-4475
US

IV. Provider business mailing address

1235 WILLOWDALE LN
IRVING TX
75063-4475
US

V. Phone/Fax

Practice location:
  • Phone: 214-274-9533
  • Fax:
Mailing address:
  • Phone: 214-274-9533
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number5975T
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number5975T
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: