Provider Demographics
NPI:1760576979
Name:WATANABE, DEBORAH SHIZU (OD)
Entity Type:Individual
Prefix:
First Name:DEBORAH
Middle Name:SHIZU
Last Name:WATANABE
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 1:1600 W 38TH ST STE 406
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78731-6407
Mailing Address - Country:US
Mailing Address - Phone:512-452-8598
Mailing Address - Fax:
Practice Address - Street 1:1600 W 38TH ST STE 406
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78731-6407
Practice Address - Country:US
Practice Address - Phone:512-452-8598
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2010-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX05056TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX12122OtherSPECTERA
TX81470QOtherBLUE CROSS BLUE SHIELD
TX179446301Medicaid
TXWA1830313OtherCHARITY VISION
TX8G4110Medicare ID - Type Unspecified
TX81470QOtherBLUE CROSS BLUE SHIELD
TXWA1830313OtherCHARITY VISION