Provider Demographics
NPI:1467736439
Name:OBANA, JUSTIN (OD)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:
Last Name:OBANA
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 1:818 N HIGHWAY 67
Mailing Address - Street 2:STE 104
Mailing Address - City:CEDAR HILL
Mailing Address - State:TX
Mailing Address - Zip Code:75104-2102
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:818 N HIGHWAY 67
Practice Address - Street 2:
Practice Address - City:CEDAR HILL
Practice Address - State:TX
Practice Address - Zip Code:75104-2102
Practice Address - Country:US
Practice Address - Phone:972-293-2020
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-07
Last Update Date:2021-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX8773TG152W00000X
IL046.010927152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist