Provider Demographics
NPI:1497763411
Name:TANCK, STEPHANIE D (OD)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:D
Last Name:TANCK
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:D
Other - Last Name:NANCE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3900 JOE RAMSEY BLVD E
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75401-7727
Mailing Address - Country:US
Mailing Address - Phone:903-455-0220
Mailing Address - Fax:903-455-2845
Practice Address - Street 1:6435 S FM 549 STE 100
Practice Address - Street 2:
Practice Address - City:HEATH
Practice Address - State:TX
Practice Address - Zip Code:75032-6221
Practice Address - Country:US
Practice Address - Phone:972-722-7055
Practice Address - Fax:972-722-2688
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2012-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX05737TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX151712002Medicaid
TX8K6960Medicare PIN
U76235Medicare UPIN
TX151712002Medicaid
TX8J6986Medicare PIN