Provider Demographics
NPI:1487870309
Name:ADVANCED EYECARE ASSOCIATES PC
Entity type:Organization
Organization Name:ADVANCED EYECARE ASSOCIATES PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:D
Authorized Official - Last Name:DERRYBERRY
Authorized Official - Suffix:JR
Authorized Official - Credentials:OD
Authorized Official - Phone:972-931-2020
Mailing Address - Street 1:18170 DALLAS PKWY
Mailing Address - Street 2:SUITE 402
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75287-7137
Mailing Address - Country:US
Mailing Address - Phone:972-931-2020
Mailing Address - Fax:972-407-9452
Practice Address - Street 1:18170 DALLAS PKWY
Practice Address - Street 2:SUITE 402
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75287-7137
Practice Address - Country:US
Practice Address - Phone:972-931-2020
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-18
Last Update Date:2009-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX4584TG152WC0802X, 152WP0200X, 152WS0006X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact ManagementGroup - Single Specialty
No152WP0200XEye and Vision Services ProvidersOptometristPediatricsGroup - Single Specialty
No152WS0006XEye and Vision Services ProvidersOptometristSports VisionGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0A3610OtherMEDICARE PTAN GROUP
TX2061598OtherFIRST HEALTH GROUP #
TX95266OtherHARRINGTON GROUP #
TX093085101Medicaid
TX2061598OtherFIRST HEALTH GROUP #