Provider Demographics
NPI:1801313382
Name:TANOUS, JORDAN (OD)
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:
Last Name:TANOUS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5001 W WACO DR
Mailing Address - Street 2:
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76710-7021
Mailing Address - Country:US
Mailing Address - Phone:888-792-8588
Mailing Address - Fax:
Practice Address - Street 1:5001 W WACO DR
Practice Address - Street 2:
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76710-7021
Practice Address - Country:US
Practice Address - Phone:888-792-8588
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-25
Last Update Date:2017-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX9327T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist