Healthcare Provider Details

I. General information

NPI: 1154763340
Provider Name (Legal Business Name): LONG DO O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/29/2013
Last Update Date: 07/01/2026
Certification Date: 07/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5201 BOSQUE BLVD STE 220
WACO TX
76710-4676
US

IV. Provider business mailing address

1001 RHONE LN
SOUTHLAKE TX
76092-1449
US

V. Phone/Fax

Practice location:
  • Phone: 254-741-1022
  • Fax: 817-473-0950
Mailing address:
  • Phone: 817-262-2145
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number8143TG
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code152WV0400X
TaxonomyVision Therapy Optometrist
License Number8143TG
License Number StateTX
# 3
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number8143TG
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: