Basic Information
| Provider Information | |||||||||
| NPI: | 1205909272 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | TEXARKANA EYE ASSOCIATES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2703 RICHMOND RD | ||||||||
| Address2: | |||||||||
| City: | TEXARKANA | ||||||||
| State: | TX | ||||||||
| PostalCode: | 755032328 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9038380783 | ||||||||
| FaxNumber: | 9038316145 | ||||||||
| Practice Location | |||||||||
| Address1: | 2703 RICHMOND RD | ||||||||
| Address2: | |||||||||
| City: | TEXARKANA | ||||||||
| State: | TX | ||||||||
| PostalCode: | 755032328 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9038380783 | ||||||||
| FaxNumber: | 9038316145 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/16/2006 | ||||||||
| LastUpdateDate: | 09/30/2011 | ||||||||
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| AuthorizedOfficialLastName: | FENTON | ||||||||
| AuthorizedOfficialFirstName: | ELVIN | ||||||||
| AuthorizedOfficialMiddleName: | W | ||||||||
| AuthorizedOfficialTitleorPosition: | DOCTOR | ||||||||
| AuthorizedOfficialTelephone: | 9038380783 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | OD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 5241T | TX | Y | 193400000X SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 8P157 | 01 | AR | AR BCBS | OTHER | 019333601 | 05 | TX | MEDICAID | 00E39Y | 01 | TX | BCBS GROUP NUMBER | OTHER | 134244722 | 05 | AR | MEDICAID |