Basic Information
| Provider Information | |||||||||
| NPI: | 1629795851 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BOULDER EYE SURGEONS | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 200564 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 753200564 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3077737144 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1810 30TH ST STE B | ||||||||
| Address2: | |||||||||
| City: | BOULDER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 803011025 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7203589415 | ||||||||
| FaxNumber: | 3034992020 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/27/2022 | ||||||||
| LastUpdateDate: | 10/27/2022 | ||||||||
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| AuthorizedOfficialLastName: | GRAY | ||||||||
| AuthorizedOfficialFirstName: | NIKISHA | ||||||||
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| AuthorizedOfficialTitleorPosition: | CREDENTIALING | ||||||||
| AuthorizedOfficialTelephone: | 3077737144 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | BOULDER EYE SURGEONS | ||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| NPICertificationDate: | 10/27/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | N | 193200000X MULTI-SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist | 207W00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Ophthalmology |
No ID Information.