Provider Demographics
NPI:1871686055
Name:EASTER, SANDRA L (OD)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:L
Last Name:EASTER
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 1:8614 WESTWOOD CENTER DR FL 9
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22182-2442
Mailing Address - Country:US
Mailing Address - Phone:972-279-2020
Mailing Address - Fax:972-279-2637
Practice Address - Street 1:610 N TWNEAST BLVD STE 100
Practice Address - Street 2:
Practice Address - City:MESQUITE
Practice Address - State:TX
Practice Address - Zip Code:75150-4705
Practice Address - Country:US
Practice Address - Phone:972-279-2020
Practice Address - Fax:972-279-2637
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-02
Last Update Date:2023-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KSKS1547152W00000X
332H00000X
TX5699152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100343690BMedicaid
KS5674350001Medicare NSC
KS650761Medicare PIN
KS100343690BMedicaid