Basic Information
| Provider Information | |||||||||
| NPI: | 1780864066 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MIDWAY EYE ASSOCIATES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3405 MIDWAY RD | ||||||||
| Address2: | SUITE 421 | ||||||||
| City: | PLANO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750938138 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9728012727 | ||||||||
| FaxNumber: | 9729433485 | ||||||||
| Practice Location | |||||||||
| Address1: | 3405 MIDWAY RD | ||||||||
| Address2: | SUITE 421 | ||||||||
| City: | PLANO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750938138 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9728012727 | ||||||||
| FaxNumber: | 9729433485 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/05/2007 | ||||||||
| LastUpdateDate: | 11/07/2007 | ||||||||
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| AuthorizedOfficialLastName: | BROUSSARD | ||||||||
| AuthorizedOfficialFirstName: | DEBORAH | ||||||||
| AuthorizedOfficialMiddleName: | ANN | ||||||||
| AuthorizedOfficialTitleorPosition: | OPTOMETRIST | ||||||||
| AuthorizedOfficialTelephone: | 9728012727 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | O.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152WC0802X | 6060TG | TX | Y | 193400000X SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist | Corneal and Contact Management |
ID Information
| ID | Type | State | Issuer | Description | 0081FB | 01 | TX | BCBS GROUP | OTHER |