Provider Demographics
NPI:1376990523
Name:HERNANDEZ, LAUREN BROOKE (OD)
Entity Type:Individual
Prefix:DR
First Name:LAUREN
Middle Name:BROOKE
Last Name:HERNANDEZ
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 1:4224 TEXAS BLVD
Mailing Address - Street 2:
Mailing Address - City:TEXARKANA
Mailing Address - State:TX
Mailing Address - Zip Code:75503-3013
Mailing Address - Country:US
Mailing Address - Phone:479-216-4548
Mailing Address - Fax:
Practice Address - Street 1:4224 TEXAS BLVD
Practice Address - Street 2:
Practice Address - City:TEXARKANA
Practice Address - State:TX
Practice Address - Zip Code:75503-3013
Practice Address - Country:US
Practice Address - Phone:479-216-4548
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-18
Last Update Date:2016-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX9017T152W00000X
AR2741152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist