Provider Demographics
NPI:1982684502
Name:MCCOMBS, JERRY L (OD)
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:L
Last Name:MCCOMBS
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:PO BOX 831
Mailing Address - Street 2:
Mailing Address - City:TEAGUE
Mailing Address - State:TX
Mailing Address - Zip Code:75860-0831
Mailing Address - Country:US
Mailing Address - Phone:254-739-2020
Mailing Address - Fax:254-739-2244
Practice Address - Street 1:313 MAIN ST
Practice Address - Street 2:
Practice Address - City:TEAGUE
Practice Address - State:TX
Practice Address - Zip Code:75860-1621
Practice Address - Country:US
Practice Address - Phone:254-739-2020
Practice Address - Fax:254-739-2244
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-19
Last Update Date:2008-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX02855TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX093270901Medicaid
TX00E50DOtherBCBS
TX0166540001Medicare NSC
TX093270901Medicaid