1821007675 NPI number — TEXAS RETINA ASSOCIATES

Table of content: (NPI 1821007675)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1821007675 NPI number — TEXAS RETINA ASSOCIATES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TEXAS RETINA ASSOCIATES
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:
1821007675
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/16/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 650037
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DALLAS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75265-0037
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
214-696-2008
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1708 COIT RD
Provider Second Line Business Practice Location Address:
SUITE 215
Provider Business Practice Location Address City Name:
PLANO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75075-5024
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
972-596-9222
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/07/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BROCKETTE
Authorized Official First Name:
JEFFEREY
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
214-692-6941

Provider Taxonomy Codes

  • Taxonomy code: 207W00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 094850704 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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