Provider Demographics
NPI:1912312430
Name:NATHU, POONAM VIRENDRA (OD)
Entity type:Individual
Prefix:DR
First Name:POONAM
Middle Name:VIRENDRA
Last Name:NATHU
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 1:5253 SYLVAN SHORES DR
Mailing Address - Street 2:
Mailing Address - City:FRISCO
Mailing Address - State:TX
Mailing Address - Zip Code:75034-6411
Mailing Address - Country:US
Mailing Address - Phone:714-651-6993
Mailing Address - Fax:
Practice Address - Street 1:5253 SYLVAN SHORES DR
Practice Address - Street 2:
Practice Address - City:FRISCO
Practice Address - State:TX
Practice Address - Zip Code:75034-6411
Practice Address - Country:US
Practice Address - Phone:714-651-6993
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-23
Last Update Date:2014-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX8572T152WV0400X, 152WP0200X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WV0400XEye and Vision Services ProvidersOptometristVision Therapy
No152WP0200XEye and Vision Services ProvidersOptometristPediatrics