Provider Demographics
NPI:1073919833
Name:WOODLANDS 2020 VISION
Entity Type:Organization
Organization Name:WOODLANDS 2020 VISION
Other - Org Name:WOODLANDS 2020 VISION
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO/OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:CROSBY
Authorized Official - Middle Name:W
Authorized Official - Last Name:WALLACE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:281-355-9090
Mailing Address - Street 1:1440 LAKE WOODLANDS DR
Mailing Address - Street 2:
Mailing Address - City:SPRING
Mailing Address - State:TX
Mailing Address - Zip Code:77380-3273
Mailing Address - Country:US
Mailing Address - Phone:832-412-2020
Mailing Address - Fax:
Practice Address - Street 1:1440 LAKE WOODLANDS DR
Practice Address - Street 2:
Practice Address - City:SPRING
Practice Address - State:TX
Practice Address - Zip Code:77380-3273
Practice Address - Country:US
Practice Address - Phone:832-412-2020
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-06
Last Update Date:2014-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX5527TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX092991101Medicaid