Provider Demographics
NPI:1700835782
Name:PHOLVICHITR, PAUL P (OD)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:P
Last Name:PHOLVICHITR
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 1:1509 N ZARAGOZA RD
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79936-7906
Mailing Address - Country:US
Mailing Address - Phone:915-779-7355
Mailing Address - Fax:915-778-0520
Practice Address - Street 1:1509 N ZARAGOZA RD
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79936
Practice Address - Country:US
Practice Address - Phone:915-779-7355
Practice Address - Fax:915-778-0520
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-08
Last Update Date:2019-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX4859T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0192676-01Medicaid
TX00072XMedicare ID - Type Unspecified