Provider Demographics
NPI:1295743979
Name:DEFEO, VICTORIA (OD)
Entity type:Individual
Prefix:
First Name:VICTORIA
Middle Name:
Last Name:DEFEO
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 1:14900 AVERY RANCH BLVD
Mailing Address - Street 2:B500
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78717-3951
Mailing Address - Country:US
Mailing Address - Phone:512-255-7987
Mailing Address - Fax:512-255-4351
Practice Address - Street 1:14900 AVERY RANCH BLVD
Practice Address - Street 2:B500
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78717-3951
Practice Address - Country:US
Practice Address - Phone:512-255-7987
Practice Address - Fax:512-255-4351
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX6067T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXU94165Medicare UPIN
TX8E0458Medicare ID - Type Unspecified