=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083135404
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BENJAMIN DEAN COLSTON OD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/06/2017
-----------------------------------------------------
Last Update Date | 04/26/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3150 EAST BROAD STREET SUITE 120
-----------------------------------------------------
City | MANSFIELD
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76063
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-477-6363
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3150 EAST BROAD STREET SUITE 120
-----------------------------------------------------
City | MANSFIELD
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76063
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-477-6363
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 9224T
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 152WC0802X
-----------------------------------------------------
Taxonomy Name | Corneal and Contact Management Optometrist
-----------------------------------------------------
License Number | 9224T
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 9224TG
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------