1619195047 NPI number — PEDIATRIC OPHTHALMOLOGY PA

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 1619195047 NPI number — PEDIATRIC OPHTHALMOLOGY PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PEDIATRIC OPHTHALMOLOGY 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:
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:
1619195047
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/08/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8222 DOUGLAS AVE
Provider Second Line Business Mailing Address:
STE 400
Provider Business Mailing Address City Name:
DALLAS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75225-5923
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
214-369-6434
Provider Business Mailing Address Fax Number:
214-696-6273

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1631 LANCASTER DR
Provider Second Line Business Practice Location Address:
# 200
Provider Business Practice Location Address City Name:
GRAPEVINE
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76051-3585
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
817-329-5433
Provider Business Practice Location Address Fax Number:
817-329-5532
Provider Enumeration Date:
04/23/2007

Additional Information

Authorized Official

Authorized Official Last Name:
STAGER
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
R
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
214-369-6434

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: 130345509 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com