Provider Demographics
NPI:1669448411
Name:HOLBROOK, AMELIA JACOBSON (OD)
Entity Type:Individual
Prefix:DR
First Name:AMELIA
Middle Name:JACOBSON
Last Name:HOLBROOK
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 1:2470 GRAY FALLS DR STE 150
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77077-6525
Mailing Address - Country:US
Mailing Address - Phone:281-556-5353
Mailing Address - Fax:
Practice Address - Street 1:15080 MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77079-4302
Practice Address - Country:US
Practice Address - Phone:281-531-0300
Practice Address - Fax:281-531-0349
Is Sole Proprietor?:No
Enumeration Date:2006-02-23
Last Update Date:2012-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX3947TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1034886-01Medicaid
TX1034886-02Medicaid
TX300182801Medicaid
1128940001Medicare NSC
TXTXB129053Medicare PIN
TX1034886-02Medicaid
TXTXB132238Medicare PIN
TXT91720Medicare UPIN
1127550003Medicare NSC
1127550004Medicare NSC