Provider Demographics
NPI:1124672225
Name:BAY AREA OPTOMETRY GROUP
Entity type:Organization
Organization Name:BAY AREA OPTOMETRY GROUP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JOSHUA
Authorized Official - Middle Name:RYAN
Authorized Official - Last Name:DEVERA
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:281-910-4604
Mailing Address - Street 1:6106 TIMBERMOSS CT
Mailing Address - Street 2:
Mailing Address - City:LEAGUE CITY
Mailing Address - State:TX
Mailing Address - Zip Code:77573-2592
Mailing Address - Country:US
Mailing Address - Phone:281-910-4604
Mailing Address - Fax:
Practice Address - Street 1:3457 CLEAR LAKE CITY BLVD # 500
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77059-2516
Practice Address - Country:US
Practice Address - Phone:281-910-4604
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-07-26
Last Update Date:2020-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty