Provider Demographics
NPI:1114116696
Name:M. ELAINE VLASAK, OD, PA
Entity Type:Organization
Organization Name:M. ELAINE VLASAK, OD, PA
Other - Org Name:CUSTOM EYE CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARIE
Authorized Official - Middle Name:ELAINE
Authorized Official - Last Name:VLASAK
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:210-699-3937
Mailing Address - Street 1:17503 LA CANTERA PKWY
Mailing Address - Street 2:SUITE 115
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78257-8207
Mailing Address - Country:US
Mailing Address - Phone:210-699-3937
Mailing Address - Fax:210-200-6339
Practice Address - Street 1:17503 LA CANTERA PKWY
Practice Address - Street 2:SUITE 115
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78257-8207
Practice Address - Country:US
Practice Address - Phone:210-699-3937
Practice Address - Fax:210-200-6339
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-19
Last Update Date:2011-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX5039TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0933426-03Medicaid
TXU57756Medicare UPIN
TX00Y583Medicare PIN