MEDICARE: MISS DIVYA JITENDRA MISTRY OD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	11675TG	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	11675TG	OTHER	TX	OPTOMETRY LICENSE

General Provider Information

NPI Number	:	1477489995
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS DIVYA JITENDRA MISTRY OD

Provider Business Mailing Address
First Line	:	4401 MARTIN LUTHER KING BLVD
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77204-2020
Country	:	US
Telephone Number	:	713-743-1921
Fax Number	:	713-743-0963

Provider Business Practice Location Address
First Line	:	2525 LUCAS DR
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75219-1804
Country	:	US
Telephone Number	:	214-528-7354
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/22/2026
Last Update Date	:	06/22/2026

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