Provider Demographics
NPI:1134136096
Name:PHILLIPS, JEFFREY SCOTT (OD)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:SCOTT
Last Name:PHILLIPS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4504 TEXAS BLVD
Mailing Address - Street 2:
Mailing Address - City:TEXARKANA
Mailing Address - State:TX
Mailing Address - Zip Code:75503-3027
Mailing Address - Country:US
Mailing Address - Phone:903-792-3705
Mailing Address - Fax:903-794-5008
Practice Address - Street 1:4504 TEXAS BLVD
Practice Address - Street 2:
Practice Address - City:TEXARKANA
Practice Address - State:TX
Practice Address - Zip Code:75503-3027
Practice Address - Country:US
Practice Address - Phone:903-792-3705
Practice Address - Fax:903-794-5008
Is Sole Proprietor?:No
Enumeration Date:2006-08-02
Last Update Date:2020-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX05480TG152WV0400X
TX5480TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WV0400XEye and Vision Services ProvidersOptometristVision Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX82857QOtherBLUE CROSS BLUE SHIELD
AR140981722Medicaid
AR98441OtherARKANSAS BLUE CROSS BLUE
TX019156101OtherTEXAS MEDICAID
TX410046137OtherRAILROAD MEDICARE
TX410046137OtherRAILROAD MEDICARE
TX82857QOtherBLUE CROSS BLUE SHIELD
AR140981722Medicaid