1982720637 NPI number — TEXAS STATE OPTICAL

Table of content: (NPI 1982720637)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1982720637 NPI number — TEXAS STATE OPTICAL

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TEXAS STATE OPTICAL
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:
1982720637
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/17/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
564 NORTHWEST MALL
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HOUSTON
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77092-8544
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
713-681-2467
Provider Business Mailing Address Fax Number:
713-681-0537

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
564 NORTHWEST MALL
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HOUSTON
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77092-8544
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
713-681-2467
Provider Business Practice Location Address Fax Number:
713-681-0537
Provider Enumeration Date:
03/22/2007

Additional Information

Authorized Official

Authorized Official Last Name:
SIEGEL
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
E
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
713-681-2467

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  2141 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 332H00000X , with the licence number: 2141 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: G000E92A2 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 6306 . This is a "AVESIS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 902815 . This is a "BLOCK VISION" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 16114 . This is a "SPECTERA" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 143837 . This is a "EYE MED" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: QMP000003344370 . This is a "MOLINA" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 5595 . This is a "SAFEGAURD" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 019563801 . This is a "MEDICAID" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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