Provider Demographics
NPI:1477886018
Name:FELTON, THEODORE J (OD)
Entity Type:Individual
Prefix:
First Name:THEODORE
Middle Name:J
Last Name:FELTON
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 1:204 GATEWAY N
Mailing Address - Street 2:SUITE A
Mailing Address - City:MARBLE FALLS
Mailing Address - State:TX
Mailing Address - Zip Code:78654-6361
Mailing Address - Country:US
Mailing Address - Phone:830-693-5868
Mailing Address - Fax:830-798-8017
Practice Address - Street 1:204 GATEWAY N
Practice Address - Street 2:SUITE A
Practice Address - City:MARBLE FALLS
Practice Address - State:TX
Practice Address - Zip Code:78654-6361
Practice Address - Country:US
Practice Address - Phone:830-693-5868
Practice Address - Fax:830-798-8017
Is Sole Proprietor?:No
Enumeration Date:2009-09-15
Last Update Date:2012-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX03781TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX209901201Medicaid
TX8L20364Medicare PIN
TXTXB148760Medicare PIN