1023128568 NPI number — RETINA INSTITUTE OF TEXAS PA

Table of content: (NPI 1023128568)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023128568 NPI number — RETINA INSTITUTE OF TEXAS PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RETINA INSTITUTE OF TEXAS PA
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:
6
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:
1023128568
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/23/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3414 OAK GROVE AVE
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:
75204-2375
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
214-521-1153
Provider Business Mailing Address Fax Number:
214-219-3651

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3414 OAK GROVE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DALLAS
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75204-2375
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
214-521-1153
Provider Business Practice Location Address Fax Number:
214-219-3651
Provider Enumeration Date:
08/30/2006

Additional Information

Authorized Official

Authorized Official Last Name:
KOZIELEC
Authorized Official First Name:
GREGORY
Authorized Official Middle Name:
F.
Authorized Official Title or Position:
VICE PRESIDENT
Authorized Official Telephone Number:
214-521-1153

Provider Taxonomy Codes

  • Taxonomy code: 207W00000X , with the licence number:  NA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207WX0107X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 00T587 . This is a "BCBS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 085316002 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 168301002 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 200052590 A , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".
  • Identifier: CJ5857 . This is a "RR MEDICARE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com