Provider Demographics
NPI:1093992752
Name:BAYBROOK VISION CENTER OPTOMETRY GROUP
Entity Type:Organization
Organization Name:BAYBROOK VISION CENTER OPTOMETRY GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DAN
Authorized Official - Middle Name:G
Authorized Official - Last Name:TOM
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:281-488-7033
Mailing Address - Street 1:1520 W BAY AREA BLVD
Mailing Address - Street 2:SUITE 1
Mailing Address - City:FRIENDSWOOD
Mailing Address - State:TX
Mailing Address - Zip Code:77546-2600
Mailing Address - Country:US
Mailing Address - Phone:281-488-7033
Mailing Address - Fax:281-488-4423
Practice Address - Street 1:1520 W BAY AREA BLVD
Practice Address - Street 2:SUITE 1
Practice Address - City:FRIENDSWOOD
Practice Address - State:TX
Practice Address - Zip Code:77546-2600
Practice Address - Country:US
Practice Address - Phone:281-488-7033
Practice Address - Fax:281-488-4423
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-24
Last Update Date:2018-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX03230TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX67FEOtherBCBS NUMBER
TX=========OtherTAX IDENTIFICATION NUMBER