Provider Demographics
NPI:1093750853
Name:TEXAS RETINA ASSOCIATES
Entity Type:Organization
Organization Name:TEXAS RETINA ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JEFFEREY
Authorized Official - Middle Name:T
Authorized Official - Last Name:BROCKETTE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:214-692-6941
Mailing Address - Street 1:PO BOX 650037
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75265-0037
Mailing Address - Country:US
Mailing Address - Phone:214-696-2008
Mailing Address - Fax:
Practice Address - Street 1:4517 98TH ST
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79424-5013
Practice Address - Country:US
Practice Address - Phone:806-792-0066
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-17
Last Update Date:2011-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX094850703Medicaid
NMG4476Medicaid
NMG4476Medicaid
TX00291YMedicare PIN