Provider Demographics
NPI:1720514318
Name:ODTRAVELER PLLC
Entity Type:Organization
Organization Name:ODTRAVELER PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:
Authorized Official - Last Name:MCDANIEL
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:214-724-8524
Mailing Address - Street 1:833 W DAVIS ST
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75208-4954
Mailing Address - Country:US
Mailing Address - Phone:214-484-4675
Mailing Address - Fax:214-377-7181
Practice Address - Street 1:833 W DAVIS ST
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75208-4954
Practice Address - Country:US
Practice Address - Phone:214-484-4675
Practice Address - Fax:214-377-7181
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-03
Last Update Date:2017-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX6233TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
8B5887Medicare UPIN