Provider Demographics
NPI:1972721785
Name:ODESSA ADVANCED EYE CARE, PA
Entity type:Organization
Organization Name:ODESSA ADVANCED EYE CARE, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INSURANCE SPECIALIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:IRMA
Authorized Official - Middle Name:
Authorized Official - Last Name:URIAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:432-550-4245
Mailing Address - Street 1:4702 E UNIVERSITY BLVD
Mailing Address - Street 2:
Mailing Address - City:ODESSA
Mailing Address - State:TX
Mailing Address - Zip Code:79762-8105
Mailing Address - Country:US
Mailing Address - Phone:432-550-4245
Mailing Address - Fax:432-550-4370
Practice Address - Street 1:4702 E UNIVERSITY BLVD
Practice Address - Street 2:
Practice Address - City:ODESSA
Practice Address - State:TX
Practice Address - Zip Code:79762-8105
Practice Address - Country:US
Practice Address - Phone:432-550-4245
Practice Address - Fax:432-550-4370
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ODESSA ADVANCED EYE CARE, PA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-04-24
Last Update Date:2010-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX3371TG152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact ManagementGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXT15005Medicare UPIN
TX0924920001Medicare NSC