Provider Demographics
NPI:1245276443
Name:JOE, BOB (OD)
Entity type:Individual
Prefix:DR
First Name:BOB
Middle Name:
Last Name:JOE
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 1:8105 SHOAL CREEK BLVD
Mailing Address - Street 2:SUITE A
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78757-8040
Mailing Address - Country:US
Mailing Address - Phone:512-454-4641
Mailing Address - Fax:512-454-1065
Practice Address - Street 1:8105 SHOAL CREEK BLVD
Practice Address - Street 2:SUITE A
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78757-8040
Practice Address - Country:US
Practice Address - Phone:512-454-4641
Practice Address - Fax:512-454-1065
Is Sole Proprietor?:No
Enumeration Date:2006-06-22
Last Update Date:2008-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2286TG152W00000X, 152WC0802X, 152WP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152WP0200XEye and Vision Services ProvidersOptometristPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX81662QOtherBCBS UPIN
TX81662QOtherBCBS UPIN
TX8F4927Medicare PIN