Basic Information
| Provider Information | |||||||||
| NPI: | 1659392835 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ANJONETTE COLVIN, OD, PA | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | HERITAGE FAMILY EYECARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 9816 N BEACH ST | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 762446184 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8177412020 | ||||||||
| FaxNumber: | 8177413937 | ||||||||
| Practice Location | |||||||||
| Address1: | 9816 N BEACH ST | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 762446184 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8177412020 | ||||||||
| FaxNumber: | 8177413937 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/22/2006 | ||||||||
| LastUpdateDate: | 11/30/2016 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | COLVIN | ||||||||
| AuthorizedOfficialFirstName: | ANJONETTE | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER/ OPTOMETRIST | ||||||||
| AuthorizedOfficialTelephone: | 8177412020 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | OD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 6164TG | TX | Y | 193400000X SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
No ID Information.