Provider Demographics
NPI:1831599539
Name:ILIDAN, JANET
Entity type:Individual
Prefix:
First Name:JANET
Middle Name:
Last Name:ILIDAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13200 CIRCLE N DR E
Mailing Address - Street 2:
Mailing Address - City:HELOTES
Mailing Address - State:TX
Mailing Address - Zip Code:78023-4102
Mailing Address - Country:US
Mailing Address - Phone:940-337-0104
Mailing Address - Fax:
Practice Address - Street 1:1100 WILFORD HALL LOOP BLDG 4554
Practice Address - Street 2:
Practice Address - City:JBSA LACKLAND
Practice Address - State:TX
Practice Address - Zip Code:78236-5638
Practice Address - Country:US
Practice Address - Phone:210-292-6255
Practice Address - Fax:210-292-7934
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-29
Last Update Date:2025-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0003050152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist