MEDICARE: DR. DEANNA J POWELL O.D.

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	8320T	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	203384798	OTHER	KS	FREEDOM NETWORK
2	20338479866220A002	OTHER	KS	TRICARE
3	31795041	OTHER	KS	BC/BS OF KC
4	7038483	OTHER	KS	AETNA
5	20-3384798	OTHER	KS	UHC

General Provider Information

NPI Number	:	1710940564
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DEANNA J POWELL O.D.

Provider Business Mailing Address
First Line	:	12934 GRANDSTAND WAY
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76244-7280
Country	:	US
Telephone Number	:	904-584-2230
Fax Number	:	913-254-9613

Provider Business Practice Location Address
First Line	:	1228 US 377
Second Line	:
City	:	ROANOKE
State	:	TX
Zip	:	76262-7280
Country	:	US
Telephone Number	:	904-584-2230
Fax Number	:	913-254-9613

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

Provider Enumeration Date	:	04/11/2006
Last Update Date	:	10/01/2021

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