Provider Demographics
NPI:1811200389
Name:KAVANAUGH, MINDI GREENE (OD)
Entity Type:Individual
Prefix:
First Name:MINDI
Middle Name:GREENE
Last Name:KAVANAUGH
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:MINDI
Other - Middle Name:
Other - Last Name:MEIER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:725 E VILLA MARIA RD STE 1500
Mailing Address - Street 2:
Mailing Address - City:BRYAN
Mailing Address - State:TX
Mailing Address - Zip Code:77802-5345
Mailing Address - Country:US
Mailing Address - Phone:979-775-4900
Mailing Address - Fax:979-775-4949
Practice Address - Street 1:725 E VILLA MARIA RD STE 1500
Practice Address - Street 2:
Practice Address - City:BRYAN
Practice Address - State:TX
Practice Address - Zip Code:77802-5345
Practice Address - Country:US
Practice Address - Phone:979-775-4900
Practice Address - Fax:979-775-4949
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-26
Last Update Date:2023-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX5828T152WP0200X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WP0200XEye and Vision Services ProvidersOptometristPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX5828TOtherOPTOMETY LICENSE NUMBER