Provider Demographics
NPI:1194706861
Name:BANK, IVAN BRUCE (OD ,FAAO)
Entity type:Individual
Prefix:DR
First Name:IVAN
Middle Name:BRUCE
Last Name:BANK
Suffix:
Gender:M
Credentials:OD ,FAAO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8611 HILLCREST AVE
Mailing Address - Street 2:STE. 140
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75225-4207
Mailing Address - Country:US
Mailing Address - Phone:214-739-8611
Mailing Address - Fax:214-739-8612
Practice Address - Street 1:8611 HILLCREST AVE
Practice Address - Street 2:STE. 140
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75225-4207
Practice Address - Country:US
Practice Address - Phone:214-739-8611
Practice Address - Fax:214-739-8612
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-09
Last Update Date:2015-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA930-108T152WC0802X
TX03313TG152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2264BOtherBLUE CROSS BLUE SHIELD
LA83020OtherCOVENTRY HEALTHCARE
LA721030686BAOtherHUMANA
LA47730Medicare PIN
LA721030686BAOtherHUMANA