Provider Demographics
NPI:1518246057
Name:TA, DIANE (OD)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:
Last Name:TA
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5742 MALCOMBORO DR
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77041-6582
Mailing Address - Country:US
Mailing Address - Phone:843-450-0746
Mailing Address - Fax:
Practice Address - Street 1:1035 HICKORY CREEK BLVD
Practice Address - Street 2:
Practice Address - City:HICKORY CREEK
Practice Address - State:TX
Practice Address - Zip Code:75065-7552
Practice Address - Country:US
Practice Address - Phone:940-626-0088
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-16
Last Update Date:2011-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX7771T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist