Provider Demographics
NPI:1285660654
Name:AGNEW, TODD J (OD)
Entity type:Individual
Prefix:
First Name:TODD
Middle Name:J
Last Name:AGNEW
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 1:11442 N. CENTRAL EXPRESSWAY
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75243
Mailing Address - Country:US
Mailing Address - Phone:214-754-0000
Mailing Address - Fax:214-379-1849
Practice Address - Street 1:11442 N. CENTRAL EXPRESSWAY
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75243
Practice Address - Country:US
Practice Address - Phone:214-754-0000
Practice Address - Fax:214-379-1849
Is Sole Proprietor?:No
Enumeration Date:2006-06-25
Last Update Date:2020-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX5369TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX047938801Medicaid
TX047938801Medicaid
TXP00608721Medicare PIN
TXU67004Medicare UPIN