Provider Demographics
NPI:1124165808
Name:EYE PLASTIC SURGERY ASSOCIATES PA
Entity type:Organization
Organization Name:EYE PLASTIC SURGERY ASSOCIATES PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:LAWRENCE
Authorized Official - Last Name:MAZOW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-566-2020
Mailing Address - Street 1:7777 FOREST LANE
Mailing Address - Street 2:SUITE C-710
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75230-2571
Mailing Address - Country:US
Mailing Address - Phone:972-566-2020
Mailing Address - Fax:972-566-5454
Practice Address - Street 1:7777 FOREST LANE
Practice Address - Street 2:SUITE C-710
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75230-2571
Practice Address - Country:US
Practice Address - Phone:972-566-2020
Practice Address - Fax:972-566-5454
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-31
Last Update Date:2022-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX152936401Medicaid
TX00802TOtherPTAN
TX00802TMedicare PIN