=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114900990
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BRET B FORD OD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/25/2005
-----------------------------------------------------
Last Update Date | 06/07/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 714 HILL COUNTRY DRIVE
-----------------------------------------------------
City | KERRVILLE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78028-6066
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 830-315-3673
-----------------------------------------------------
Fax | 830-315-3939
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 714 HILL COUNTRY DRIVE
-----------------------------------------------------
City | KERRVILLE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78028-6066
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 830-315-3673
-----------------------------------------------------
Fax | 830-315-3939
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 5121T
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------