Provider Demographics
NPI:1508095092
Name:TARGET INDEPENDENT DOCTOR OF OPTOMETRY
Entity Type:Organization
Organization Name:TARGET INDEPENDENT DOCTOR OF OPTOMETRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:PHUONG
Authorized Official - Last Name:PHAN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:405-761-2872
Mailing Address - Street 1:3810 CONCORD DR
Mailing Address - Street 2:
Mailing Address - City:ROUND ROCK
Mailing Address - State:TX
Mailing Address - Zip Code:78665-1314
Mailing Address - Country:US
Mailing Address - Phone:405-761-2872
Mailing Address - Fax:
Practice Address - Street 1:18700 LIMESTONE COMMERCIAL DR
Practice Address - Street 2:
Practice Address - City:PFLUGERVILLE
Practice Address - State:TX
Practice Address - Zip Code:78660-6544
Practice Address - Country:US
Practice Address - Phone:512-990-1440
Practice Address - Fax:512-990-3691
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-07
Last Update Date:2009-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX7380T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty