Provider Demographics
NPI:1457710592
Name:RETINA SPECIALISTS OF SAN ANTONIO, PLLC
Entity type:Organization
Organization Name:RETINA SPECIALISTS OF SAN ANTONIO, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:D
Authorized Official - Last Name:BRODRICK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:210-271-7648
Mailing Address - Street 1:303 E QUINCY ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78215-1918
Mailing Address - Country:US
Mailing Address - Phone:210-271-7648
Mailing Address - Fax:210-225-8184
Practice Address - Street 1:303 E QUINCY ST
Practice Address - Street 2:SUITE 100
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78215-1918
Practice Address - Country:US
Practice Address - Phone:210-271-7648
Practice Address - Fax:210-225-8184
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-17
Last Update Date:2017-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX207WX0107X, 207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
No207WX0107XAllopathic & Osteopathic PhysiciansOphthalmologyRetina SpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX3583817-01Medicaid
TX487542Medicare PIN