Basic Information
| Provider Information | |||||||||
| NPI: | 1669653051 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DALLAS VISION CENTER INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 414 PARK FOREST CTR | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752348065 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9722418084 | ||||||||
| FaxNumber: | 9722418086 | ||||||||
| Practice Location | |||||||||
| Address1: | 11888 MARSH LN | ||||||||
| Address2: | SUITE 414 | ||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752348083 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9722418084 | ||||||||
| FaxNumber: | 9722418086 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/14/2007 | ||||||||
| LastUpdateDate: | 08/03/2010 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | VODVARKA | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9722418084 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | O.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332H00000X | TG2057 | TX | Y | Suppliers | Eyewear Supplier (Equipment, not the service) |
ID Information
| ID | Type | State | Issuer | Description | 410033055 | 01 | TX | RAILROAD PIN | OTHER | 1316922982 | 01 | TX | INDIVIDUAL NPI | OTHER | 8A8260 | 01 | TX | MEDICARE INDIVIDUAL NUMBER | OTHER |