Provider Demographics
NPI:1528026994
Name:BOOKER, VANCE WAYNE JR (OD)
Entity Type:Individual
Prefix:DR
First Name:VANCE
Middle Name:WAYNE
Last Name:BOOKER
Suffix:JR
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 1:200 CEDAR ELM CT
Mailing Address - Street 2:
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75063-8464
Mailing Address - Country:US
Mailing Address - Phone:972-401-2122
Mailing Address - Fax:
Practice Address - Street 1:239 W JEFFERSON BLVD
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75208-4510
Practice Address - Country:US
Practice Address - Phone:214-943-7604
Practice Address - Fax:214-943-6780
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1817TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXT12276Medicare UPIN
TX00E96CMedicare ID - Type Unspecified