1497869796 NPI number — RETINA ASSOCIATES OF SOUTH TEXAS, P.A.

Table of content: (NPI 1497869796)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497869796 NPI number — RETINA ASSOCIATES OF SOUTH TEXAS, P.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RETINA ASSOCIATES OF SOUTH TEXAS, P.A.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1497869796
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 356
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAN ANTONIO
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78292-0356
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
210-615-7600
Provider Business Mailing Address Fax Number:
210-615-8505

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9910 HUEBNER RD
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
SAN ANTONIO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78240-1336
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
210-615-7600
Provider Business Practice Location Address Fax Number:
210-615-8505
Provider Enumeration Date:
08/17/2006

Additional Information

Authorized Official

Authorized Official Last Name:
CLELAND
Authorized Official First Name:
TIMOTHY
Authorized Official Middle Name:
PAUL
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
210-615-7600

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 079907401 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com