Provider Demographics
NPI:1548241847
Name:VANDIVER, ZANE A (OD)
Entity Type:Individual
Prefix:DR
First Name:ZANE
Middle Name:A
Last Name:VANDIVER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7201 BOAT CLUB RD
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76179-4555
Mailing Address - Country:US
Mailing Address - Phone:817-750-2233
Mailing Address - Fax:817-750-2266
Practice Address - Street 1:7201 BOAT CLUB RD
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76179-4555
Practice Address - Country:US
Practice Address - Phone:817-750-2233
Practice Address - Fax:817-750-2266
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-14
Last Update Date:2013-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX4359TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXT40693Medicare UPIN
TX8D1982Medicare ID - Type Unspecified