Provider Demographics
NPI:1114178316
Name:MARIO A. CABALLERO OD PC
Entity Type:Organization
Organization Name:MARIO A. CABALLERO OD PC
Other - Org Name:EASTSIDE VISION CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARIO
Authorized Official - Middle Name:A
Authorized Official - Last Name:CABALLERO
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:915-592-8090
Mailing Address - Street 1:10952 BEN CRENSHAW DR
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79935-3043
Mailing Address - Country:US
Mailing Address - Phone:915-592-8090
Mailing Address - Fax:915-592-9284
Practice Address - Street 1:10952 BEN CRENSHAW DR
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79935-3043
Practice Address - Country:US
Practice Address - Phone:915-592-8090
Practice Address - Fax:915-592-9284
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-06
Last Update Date:2008-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX4921TG152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact ManagementGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXU613512Medicare UPIN
TX00E08VMedicare PIN