Basic Information
| Provider Information | |||||||||
| NPI: | 1376549600 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BYRD | ||||||||
| FirstName: | BRENDA | ||||||||
| MiddleName: | K | ||||||||
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| Credential: | O.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1201 SUMMIT AVE | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761024427 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8173322020 | ||||||||
| FaxNumber: | 8173324797 | ||||||||
| Practice Location | |||||||||
| Address1: | 1201 SUMMIT AVE | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761024427 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8173322020 | ||||||||
| FaxNumber: | 8173324797 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/22/2005 | ||||||||
| LastUpdateDate: | 12/03/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 04954TG | TX | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 82010E | 01 | TX | BCBS | OTHER |