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General NPI Number Information
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NPI Number | 1942754700
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Entity Type | Organization
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Legal Business Name | 2020 EYEDR
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Dates
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Enumeration Date | 08/10/2016
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Last Update Date | 08/10/2016
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Provider Practice Location Address
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Address Line | 1251 E SOUTHLAKE BLVD SUITE 331
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City | SOUTHLAKE
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State | TX
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Zip | 76092-6478
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Country | US
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Telephone | 630-452-6290
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Fax | 888-619-2009
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Provider Business Mailing Address
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Address Line | 1505 STONE DR
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City | CARROLLTON
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State | TX
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Zip | 75010-1147
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Country | US
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Telephone | 630-452-6290
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Fax | 888-619-2009
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Authorized Official
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Title or Position | OPTOMETRIST
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Name | DR. MANOJ ABRAHAM
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Credential | OD
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Telephone | 630-452-6290
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 8563
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License Number State | TX
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