Healthcare Provider Details

I. General information

NPI: 1134136096
Provider Name (Legal Business Name): JEFFREY SCOTT PHILLIPS OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/02/2006
Last Update Date: 03/30/2020
Certification Date: 03/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4504 TEXAS BLVD
TEXARKANA TX
75503-3027
US

IV. Provider business mailing address

4504 TEXAS BLVD
TEXARKANA TX
75503-3027
US

V. Phone/Fax

Practice location:
  • Phone: 903-792-3705
  • Fax: 903-794-5008
Mailing address:
  • Phone: 903-792-3705
  • Fax: 903-794-5008

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152WV0400X
TaxonomyVision Therapy Optometrist
License Number05480TG
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number5480TG
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: