1386728756 NPI number — GLAUCOMA SPECIALISTS OF TEXAS SHP PA

Table of content: (NPI 1386728756)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1386728756 NPI number — GLAUCOMA SPECIALISTS OF TEXAS SHP PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GLAUCOMA SPECIALISTS OF TEXAS SHP 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:
1386728756
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/30/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1602 LANCASTER DR
Provider Second Line Business Mailing Address:
SUITE 102
Provider Business Mailing Address City Name:
GRAPEVINE
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76051-3574
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
817-885-7878
Provider Business Mailing Address Fax Number:
817-885-7444

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1602 LANCASTER DR
Provider Second Line Business Practice Location Address:
SUITE 102
Provider Business Practice Location Address City Name:
GRAPEVINE
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76051-3574
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
817-885-7878
Provider Business Practice Location Address Fax Number:
817-885-7444
Provider Enumeration Date:
10/24/2006

Additional Information

Authorized Official

Authorized Official Last Name:
SMYTHE
Authorized Official First Name:
BARBARA
Authorized Official Middle Name:
A
Authorized Official Title or Position:
PHYSICIAN/CHIEF MEDICAL OFFICER
Authorized Official Telephone Number:
817-885-7878

Provider Taxonomy Codes

  • Taxonomy code: 261Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 006MN . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 1609869692 . This is a "NPI - PROVIDER" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: DD4140 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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