Provider Demographics
NPI:1497835490
Name:DISHMAN, O KEITH (OD)
Entity Type:Individual
Prefix:DR
First Name:O
Middle Name:KEITH
Last Name:DISHMAN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4311 OAK LAWN AVE
Mailing Address - Street 2:STE.# C125
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75219-2315
Mailing Address - Country:US
Mailing Address - Phone:214-521-0929
Mailing Address - Fax:214-521-2502
Practice Address - Street 1:4311 OAK LAWN AVE
Practice Address - Street 2:STE.# C125
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75219-2315
Practice Address - Country:US
Practice Address - Phone:214-521-0929
Practice Address - Fax:214-521-2502
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-16
Last Update Date:2012-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXTX1940TG152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX093189102Medicaid
TXTXB141828Medicare PIN