Provider Demographics
NPI:1447385596
Name:REDWINE, JERRY D (OD)
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:D
Last Name:REDWINE
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:PO BOX 1011
Mailing Address - Street 2:
Mailing Address - City:MULESHOE
Mailing Address - State:TX
Mailing Address - Zip Code:79347-1011
Mailing Address - Country:US
Mailing Address - Phone:806-272-4705
Mailing Address - Fax:806-272-3824
Practice Address - Street 1:111 E 3RD ST
Practice Address - Street 2:
Practice Address - City:MULESHOE
Practice Address - State:TX
Practice Address - Zip Code:79347-3801
Practice Address - Country:US
Practice Address - Phone:806-272-4705
Practice Address - Fax:806-272-3824
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-22
Last Update Date:2008-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2296T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0931693-01Medicaid
TXOOE28DMedicare PIN
TX0321040001Medicare NSC