=====================================================
General NPI Number Information
=====================================================
NPI Number | 1346252319
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PAMELA SUE SOLLY O.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/11/2006
-----------------------------------------------------
Last Update Date | 06/21/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 747 HIGHWAY 71 W SUITE A-550
-----------------------------------------------------
City | BASTROP
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78602-4096
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 512-321-3042
-----------------------------------------------------
Fax | 512-321-3083
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 747 HIGHWAY 71 W SUITE A-550
-----------------------------------------------------
City | BASTROP
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78602-4096
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 512-321-3042
-----------------------------------------------------
Fax | 512-321-3083
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 6918TG
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------