Provider Demographics
NPI:1851975718
Name:PLATT, AVERY JACQUELINE (OD)
Entity Type:Individual
Prefix:
First Name:AVERY
Middle Name:JACQUELINE
Last Name:PLATT
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:AVERY
Other - Middle Name:JACQUELINE
Other - Last Name:HUBER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:816 LAKE AIR DR
Mailing Address - Street 2:
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76710-5745
Mailing Address - Country:US
Mailing Address - Phone:254-752-0471
Mailing Address - Fax:
Practice Address - Street 1:816 LAKE AIR DR
Practice Address - Street 2:
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76710-5745
Practice Address - Country:US
Practice Address - Phone:254-752-0471
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-07
Last Update Date:2022-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TX10223TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program