Provider Demographics
NPI:1679702096
Name:SUMMERS, SEAN M (OD)
Entity Type:Individual
Prefix:MR
First Name:SEAN
Middle Name:M
Last Name:SUMMERS
Suffix:
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 1:4504 TEXAS BLVD
Mailing Address - Street 2:
Mailing Address - City:TEXARKANA
Mailing Address - State:TX
Mailing Address - Zip Code:75503-3027
Mailing Address - Country:US
Mailing Address - Phone:903-792-3705
Mailing Address - Fax:903-794-5008
Practice Address - Street 1:4504 TEXAS BLVD
Practice Address - Street 2:
Practice Address - City:TEXARKANA
Practice Address - State:TX
Practice Address - Zip Code:75503-3027
Practice Address - Country:US
Practice Address - Phone:903-792-3705
Practice Address - Fax:903-794-5008
Is Sole Proprietor?:No
Enumeration Date:2009-07-07
Last Update Date:2020-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX7424T152WV0400X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WV0400XEye and Vision Services ProvidersOptometristVision Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX7424TOtherSTATE LICENSE
TX8L19055Medicare PIN