Provider Demographics
NPI:1104208263
Name:HEREDIA, PRISCILLA ROSE (OD)
Entity Type:Individual
Prefix:DR
First Name:PRISCILLA
Middle Name:ROSE
Last Name:HEREDIA
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:708 S BIBB AVE
Mailing Address - Street 2:
Mailing Address - City:EAGLE PASS
Mailing Address - State:TX
Mailing Address - Zip Code:78852-5069
Mailing Address - Country:US
Mailing Address - Phone:830-773-7339
Mailing Address - Fax:830-773-4618
Practice Address - Street 1:708 S BIBB AVE
Practice Address - Street 2:
Practice Address - City:EAGLE PASS
Practice Address - State:TX
Practice Address - Zip Code:78852-5069
Practice Address - Country:US
Practice Address - Phone:830-773-7339
Practice Address - Fax:830-773-4618
Is Sole Proprietor?:No
Enumeration Date:2015-06-25
Last Update Date:2015-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX8680T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist