MEDICARE: JANE ELIZABETH DE GRASSE 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	5514TG	TX

General Provider Information

NPI Number	:	1851372155
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JANE ELIZABETH DE GRASSE O.D.

Provider Business Mailing Address
First Line	:	300 MERCEDES ST
Second Line	:
City	:	BENBROOK
State	:	TX
Zip	:	76126-2593
Country	:	US
Telephone Number	:	817-249-4078
Fax Number	:	817-249-4094

Provider Business Practice Location Address
First Line	:	300 MERCEDES ST
Second Line	:
City	:	BENBROOK
State	:	TX
Zip	:	76126-2593
Country	:	US
Telephone Number	:	817-249-4078
Fax Number	:	817-249-4094

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

Provider Enumeration Date	:	11/14/2005
Last Update Date	:	01/08/2014

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