Basic Information
| Provider Information | |||||||||
| NPI: | 1699016535 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ALAMO CTY EYE PHYSICIANS | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | ALAMO PHYSICIANS OPTICAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 11601 TOEPPERWEIN RD | ||||||||
| Address2: | |||||||||
| City: | LIVE OAK | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782333147 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2109462020 | ||||||||
| FaxNumber: | 2105903936 | ||||||||
| Practice Location | |||||||||
| Address1: | 3327 RESEARCH PLZ | ||||||||
| Address2: | SUITE 306 | ||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782355155 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2105998882 | ||||||||
| FaxNumber: | 2105903936 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/01/2013 | ||||||||
| LastUpdateDate: | 03/01/2013 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BERRY | ||||||||
| AuthorizedOfficialFirstName: | JON | ||||||||
| AuthorizedOfficialMiddleName: | MARK | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2109462020 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ALAMO CTY EYE PHYSICIANS | ||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | H9797 | TX | Y | Suppliers | Durable Medical Equipment & Medical Supplies |
ID Information
| ID | Type | State | Issuer | Description | 066273601 | 05 | TX | MEDICAID |