Provider Demographics
NPI:1386729903
Name:TEXAS STATE OPTICAL OF BRENHAM
Entity type:Organization
Organization Name:TEXAS STATE OPTICAL OF BRENHAM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:EUGENE
Authorized Official - Last Name:REXROAD
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:979-836-1077
Mailing Address - Street 1:2648 HIGHWAY 36 S
Mailing Address - Street 2:
Mailing Address - City:BRENHAM
Mailing Address - State:TX
Mailing Address - Zip Code:77833-9600
Mailing Address - Country:US
Mailing Address - Phone:979-836-1166
Mailing Address - Fax:979-830-1573
Practice Address - Street 1:2648 HIGHWAY 36 S
Practice Address - Street 2:
Practice Address - City:BRENHAM
Practice Address - State:TX
Practice Address - Zip Code:77833-9600
Practice Address - Country:US
Practice Address - Phone:979-836-1166
Practice Address - Fax:979-830-1573
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2133T332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00E84BMedicare ID - Type UnspecifiedMEDICARE NUMBER
TXT15508Medicare UPIN