Provider Demographics
NPI:1679623144
Name:HIGGINBOTHAM, REX MICHAEL (OD)
Entity type:Individual
Prefix:DR
First Name:REX
Middle Name:MICHAEL
Last Name:HIGGINBOTHAM
Suffix:
Gender:M
Credentials:OD
Other - Prefix:DR
Other - First Name:REX
Other - Middle Name:M
Other - Last Name:HIGGINBOTHAM
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OD
Mailing Address - Street 1:3772 HOWE ST
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94611-5311
Mailing Address - Country:US
Mailing Address - Phone:510-752-1235
Mailing Address - Fax:
Practice Address - Street 1:3772 HOWE ST
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94611-5311
Practice Address - Country:US
Practice Address - Phone:510-752-1235
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA5402T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist