Basic Information
| Provider Information | |||||||||
| NPI: | 1235106857 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MARCACCIO | ||||||||
| FirstName: | ANGELA | ||||||||
| MiddleName: | C | ||||||||
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| Credential: | O.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9006 CLIFFWOOD DR | ||||||||
| Address2: | |||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770963507 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7137292030 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1051 HALSEY ST | ||||||||
| Address2: | |||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770154959 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7134532972 | ||||||||
| FaxNumber: | 7134503609 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/02/2006 | ||||||||
| LastUpdateDate: | 07/19/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/19/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 3069 | TX | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 1548216-01 | 05 | TX | MEDICAID | 1122897-08 | 05 | TX | MEDICAID | 11616012 | 01 | TX | CAQH | OTHER |