1275715963 NPI number — TEXAS STATE OPTICAL OF BRYAN PC

Table of content: (NPI 1275715963)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275715963 NPI number — TEXAS STATE OPTICAL OF BRYAN PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TEXAS STATE OPTICAL OF BRYAN PC
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:
1275715963
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/03/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3030 E 29TH ST
Provider Second Line Business Mailing Address:
SUITE 106
Provider Business Mailing Address City Name:
BRYAN
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77802-2757
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3030 E 29TH ST
Provider Second Line Business Practice Location Address:
SUITE 106
Provider Business Practice Location Address City Name:
BRYAN
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77802-2757
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
979-731-8446
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/04/2007

Additional Information

Authorized Official

Authorized Official Last Name:
PHILLIPS
Authorized Official First Name:
GERALD
Authorized Official Middle Name:
D
Authorized Official Title or Position:
DOCTOR
Authorized Official Telephone Number:
979-731-8446

Provider Taxonomy Codes

  • Taxonomy code: 332H00000X , 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: 16110 . This is a "SPECTERA" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 6271 . This is a "AVESIS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 80323E . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 902303 . This is a "BLOCK VISION" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 112311903 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 16258 . This is a "SCOTT & WHITE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: TX2145 . This is a "EYEMED" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 59496 . This is a "SAFEGUARD" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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