Provider Demographics
NPI:1104138536
Name:CAMACHO, JEANNINE E (OD)
Entity type:Individual
Prefix:MS
First Name:JEANNINE
Middle Name:E
Last Name:CAMACHO
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:2929 MOSSROCK
Mailing Address - Street 2:SUITE 104
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78230-5141
Mailing Address - Country:US
Mailing Address - Phone:210-377-0350
Mailing Address - Fax:210-377-2982
Practice Address - Street 1:2929 MOSSROCK
Practice Address - Street 2:SUITE 104
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78230-5141
Practice Address - Country:US
Practice Address - Phone:210-377-0350
Practice Address - Fax:210-377-2982
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-14
Last Update Date:2011-10-12
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TX7546T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX213703602Medicaid
TX7546TOtherTEXAS OPTOMETRY BOARD LICENSE
TX213703602Medicaid