Healthcare Provider Details

I. General information

NPI: 1710940564
Provider Name (Legal Business Name): DEANNA J POWELL O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/11/2006
Last Update Date: 10/01/2021
Certification Date: 10/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1228 US 377
ROANOKE TX
76262-7280
US

IV. Provider business mailing address

12934 GRANDSTAND WAY
FORT WORTH TX
76244-7280
US

V. Phone/Fax

Practice location:
  • Phone: 904-584-2230
  • Fax: 913-254-9613
Mailing address:
  • Phone: 904-584-2230
  • Fax: 913-254-9613

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number8320T
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: