Provider Demographics
NPI:1114050242
Name:PEDIATRIC OPHTHALMOLOGY PA
Entity Type:Organization
Organization Name:PEDIATRIC OPHTHALMOLOGY PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:R
Authorized Official - Last Name:STAGER
Authorized Official - Suffix:SR
Authorized Official - Credentials:MD
Authorized Official - Phone:214-369-6434
Mailing Address - Street 1:8222 DOUGLAS AVE
Mailing Address - Street 2:STE 400
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75225-5923
Mailing Address - Country:US
Mailing Address - Phone:214-369-6434
Mailing Address - Fax:214-639-6273
Practice Address - Street 1:8222 DOUGLAS AVE
Practice Address - Street 2:STE 400
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75225-5923
Practice Address - Country:US
Practice Address - Phone:214-369-6434
Practice Address - Fax:214-639-6273
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-14
Last Update Date:2008-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXCD8338OtherRAILROAD MEDICARE
TX094814301Medicaid
TX094814301Medicaid