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Individual
TU DAO
Active
Individual
TU DAO
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
OD
Taxonomy
Speciality
Code
Description
License number
State
152W00000X
Optometrist
Primary
9983TG
TX
390200000X
Student in an Organized Health Care Education/Training Program
9983T
TX
Other
Enumeration date
06/18/2020
Last updated
07/28/2025
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