Provider Demographics
NPI:1285819474
Name:ADVANCED EYELID SURGERY CENTER & LASER CENTER
Entity type:Organization
Organization Name:ADVANCED EYELID SURGERY CENTER & LASER CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:MAYLI
Authorized Official - Middle Name:L
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:817-329-4480
Mailing Address - Street 1:6407 COLLEYVILLE BLVD
Mailing Address - Street 2:SUITE B
Mailing Address - City:COLLEYVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:76034-6228
Mailing Address - Country:US
Mailing Address - Phone:817-329-4480
Mailing Address - Fax:817-488-5993
Practice Address - Street 1:6407 COLLEYVILLE BLVD
Practice Address - Street 2:SUITE B
Practice Address - City:COLLEYVILLE
Practice Address - State:TX
Practice Address - Zip Code:76034-6228
Practice Address - Country:US
Practice Address - Phone:817-329-4480
Practice Address - Fax:817-488-5993
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ADVANCED EYELID SURGERY CENTER & LASER CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-01-07
Last Update Date:2008-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ5739207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0067EZOtherBCBS
TX127504201Medicaid
TX00550XMedicare PIN
TX127504201Medicaid