=====================================================
General NPI Number Information
=====================================================
NPI Number | 1669589081
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MELANIE MONTES VARDEMAN O.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/23/2006
-----------------------------------------------------
Last Update Date | 08/24/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4729 NE STALLINGS DR
-----------------------------------------------------
City | NACOGDOCHES
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75965-1607
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 936-564-2634
-----------------------------------------------------
Fax | 936-564-0387
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 632767
-----------------------------------------------------
City | NACOGDOCHES
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75963-2767
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 936-564-2634
-----------------------------------------------------
Fax | 936-564-0387
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 5757TG
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------