Basic Information
| Provider Information | |||||||||
| NPI: | 1306802012 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TRAN | ||||||||
| FirstName: | JIMMY | ||||||||
| MiddleName: | |||||||||
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| Credential: | O.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2201 WESTGATE PLZ | ||||||||
| Address2: | |||||||||
| City: | GRAPEVINE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 760518037 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8174102030 | ||||||||
| FaxNumber: | 8172516261 | ||||||||
| Practice Location | |||||||||
| Address1: | 2201 WESTGATE PLZ | ||||||||
| Address2: | |||||||||
| City: | GRAPEVINE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 760518037 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8174102030 | ||||||||
| FaxNumber: | 8172516261 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/21/2006 | ||||||||
| LastUpdateDate: | 05/27/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/27/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 4559 | MA | N | Eye and Vision Services Providers | Optometrist | 152W00000X | 6855TG | TX | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 309756003 | 05 | TX | MEDICAID |