Basic Information
| Provider Information | |||||||||
| NPI: | 1336172055 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SOWASH OPTOMETRY GROUP PC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | VISIONWORKS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 848209 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752848209 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2105246771 | ||||||||
| FaxNumber: | 2105246587 | ||||||||
| Practice Location | |||||||||
| Address1: | 355 S WADSWORTH BLVD | ||||||||
| Address2: | SUITE D | ||||||||
| City: | LAKEWOOD | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802263136 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7209626906 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/08/2006 | ||||||||
| LastUpdateDate: | 12/10/2015 | ||||||||
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| AuthorizedOfficialLastName: | SOWASH | ||||||||
| AuthorizedOfficialFirstName: | THOMAS | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 3035527137 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | OD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 92002561 | 05 | CO | MEDICAID |