Provider Demographics
NPI:1114919677
Name:KHA, CAROLYN K (OD)
Entity Type:Individual
Prefix:DR
First Name:CAROLYN
Middle Name:K
Last Name:KHA
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 1:4927 LAKE RIDGE PKWY
Mailing Address - Street 2:SUITE NUMBER 160
Mailing Address - City:GRAND PRAIRIE
Mailing Address - State:TX
Mailing Address - Zip Code:75052-3073
Mailing Address - Country:US
Mailing Address - Phone:972-641-5900
Mailing Address - Fax:972-641-5903
Practice Address - Street 1:4927 LAKE RIDGE PKWY
Practice Address - Street 2:SUITE NUMBER 160
Practice Address - City:GRAND PRAIRIE
Practice Address - State:TX
Practice Address - Zip Code:75052-3073
Practice Address - Country:US
Practice Address - Phone:972-641-5900
Practice Address - Fax:972-641-5903
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-19
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX6592TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX6592TGOtherTX OPTOMETRY BOARD
TX90136629OtherDPS REGISTRATION
TX90136629OtherDPS REGISTRATION
TX8C2286Medicare ID - Type Unspecified
TXV01179Medicare UPIN