1497778583 NPI number — BERKELEY EYE INSTITUTE, PLLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497778583 NPI number — BERKELEY EYE INSTITUTE, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BERKELEY EYE INSTITUTE, PLLC
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:
BERKELEY EYE CENTER
Provider Other Organization Name Type Code:
3
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:
1497778583
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/31/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
21502 MERCHANTS WAY STE A
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KATY
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77449-2515
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
281-944-2232
Provider Business Mailing Address Fax Number:
281-944-2290

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2012 WEST LOOP
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EL CAMPO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77437-8030
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
979-543-6821
Provider Business Practice Location Address Fax Number:
979-543-6817
Provider Enumeration Date:
07/26/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MICHELETTI
Authorized Official First Name:
MARK
Authorized Official Middle Name:
F
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
281-348-4615

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207W00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 332H00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 0072KD . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 158559801 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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