Provider Demographics
NPI:1285980383
Name:TEXOMA RETINA CENTER PA
Entity type:Organization
Organization Name:TEXOMA RETINA CENTER PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:VIJAY
Authorized Official - Middle Name:
Authorized Official - Last Name:KHETPAL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:903-337-0055
Mailing Address - Street 1:1303 N SAM RAYBURN FWY # 100
Mailing Address - Street 2:
Mailing Address - City:SHERMAN
Mailing Address - State:TX
Mailing Address - Zip Code:75090-5030
Mailing Address - Country:US
Mailing Address - Phone:903-337-0055
Mailing Address - Fax:903-337-0060
Practice Address - Street 1:1303 N SAM RAYBURN FWY # 100
Practice Address - Street 2:
Practice Address - City:SHERMAN
Practice Address - State:TX
Practice Address - Zip Code:75090-5030
Practice Address - Country:US
Practice Address - Phone:903-337-0055
Practice Address - Fax:903-337-0060
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-26
Last Update Date:2023-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207W00000X, 207WX0009X, 207WX0107X, 207WX0108X
TXP2474261QS0132X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
No207WX0009XAllopathic & Osteopathic PhysiciansOphthalmologyGlaucoma SpecialistGroup - Single Specialty
No207WX0107XAllopathic & Osteopathic PhysiciansOphthalmologyRetina SpecialistGroup - Single Specialty
No207WX0108XAllopathic & Osteopathic PhysiciansOphthalmologyUveitis and Ocular Inflammatory DiseaseGroup - Single Specialty
No261QS0132XAmbulatory Health Care FacilitiesClinic/CenterOphthalmologic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXTXB162093OtherPTAN
TX307003901Medicaid