1649261322 NPI number — DR. MARIE ELAINE VLASAK OD

Table of content: DR. MARIE ELAINE VLASAK OD (NPI 1649261322)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649261322 NPI number — DR. MARIE ELAINE VLASAK OD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VLASAK
Provider First Name:
MARIE
Provider Middle Name:
ELAINE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
OD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
VLASAK
Provider Other First Name:
M.
Provider Other Middle Name:
ELAINE
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
OD
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1649261322
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/12/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
17503 LA CANTERA PKWY
Provider Second Line Business Mailing Address:
SUITE 115
Provider Business Mailing Address City Name:
SAN ANTONIO
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78257-8207
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
210-699-3937
Provider Business Mailing Address Fax Number:
210-200-6339

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
17503 LA CANTERA PKWY
Provider Second Line Business Practice Location Address:
SUITE 115
Provider Business Practice Location Address City Name:
SAN ANTONIO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78257-8207
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
210-699-3937
Provider Business Practice Location Address Fax Number:
210-200-6339
Provider Enumeration Date:
11/02/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  5039TG , 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: 093342603 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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