Provider Demographics
NPI:1124258959
Name:FAGALA, ANDREANE BOUDREAULT (OD)
Entity type:Individual
Prefix:
First Name:ANDREANE
Middle Name:BOUDREAULT
Last Name:FAGALA
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1301 W CAMPBELL RD
Mailing Address - Street 2:
Mailing Address - City:RICHARDSON
Mailing Address - State:TX
Mailing Address - Zip Code:75080-2815
Mailing Address - Country:US
Mailing Address - Phone:972-669-9229
Mailing Address - Fax:972-669-9229
Practice Address - Street 1:1301 W CAMPBELL RD
Practice Address - Street 2:
Practice Address - City:RICHARDSON
Practice Address - State:TX
Practice Address - Zip Code:75080-2815
Practice Address - Country:US
Practice Address - Phone:972-669-9229
Practice Address - Fax:972-669-9229
Is Sole Proprietor?:No
Enumeration Date:2009-07-14
Last Update Date:2014-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX7393T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8L25055Medicare PIN