Healthcare Provider Details

I. General information

NPI: 1124258959
Provider Name (Legal Business Name): ANDREANE BOUDREAULT FAGALA O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2009
Last Update Date: 09/05/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1301 W CAMPBELL RD
RICHARDSON TX
75080-2815
US

IV. Provider business mailing address

1301 W CAMPBELL RD
RICHARDSON TX
75080-2815
US

V. Phone/Fax

Practice location:
  • Phone: 972-669-9229
  • Fax: 972-669-9229
Mailing address:
  • Phone: 972-669-9229
  • Fax: 972-669-9229

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number7393T
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: