Provider Demographics
NPI:1235323809
Name:PROVE, LESTER (ABOC, NCLE)
Entity Type:Individual
Prefix:MR
First Name:LESTER
Middle Name:
Last Name:PROVE
Suffix:
Gender:M
Credentials:ABOC, NCLE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2901 E 29TH ST STE 105
Mailing Address - Street 2:
Mailing Address - City:BRYAN
Mailing Address - State:TX
Mailing Address - Zip Code:77802-2691
Mailing Address - Country:US
Mailing Address - Phone:979-776-7111
Mailing Address - Fax:
Practice Address - Street 1:2901 E 29TH ST STE 105
Practice Address - Street 2:
Practice Address - City:BRYAN
Practice Address - State:TX
Practice Address - Zip Code:77802-2691
Practice Address - Country:US
Practice Address - Phone:979-776-7111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-28
Last Update Date:2007-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX09779001Medicaid
TX09779001Medicaid