=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134896194
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | COLLIN TUBBS OD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/26/2021
-----------------------------------------------------
Last Update Date | 08/26/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9600 S IH 35 STE S225
-----------------------------------------------------
City | AUSTIN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78748-3889
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 512-291-0876
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10300 S IH 35 UNIT 2304
-----------------------------------------------------
City | AUSTIN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78748-2659
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 512-419-8776
-----------------------------------------------------
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 | 10250T
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------