=====================================================
General NPI Number Information
=====================================================
NPI Number | 1841864212
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JORDAN RAMSSES ROMERO OD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/19/2021
-----------------------------------------------------
Last Update Date | 08/06/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 200 OGLETREE DR
-----------------------------------------------------
City | LIVINGSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77351-6420
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 936-328-5600
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 18255 RIVER SAGE DR
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77084-2485
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 832-878-6817
-----------------------------------------------------
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 | 10308TG
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------