Provider Demographics
NPI:1124578208
Name:SITTERLE VISION SOURCE PLLC
Entity Type:Organization
Organization Name:SITTERLE VISION SOURCE PLLC
Other - Org Name:SITTERLE VISION SOURCE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:CAVAZOS
Authorized Official - Last Name:MALDONADO
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:210-490-9091
Mailing Address - Street 1:2950 THOUSAND OAKS DR STE 23
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78247-3347
Mailing Address - Country:US
Mailing Address - Phone:210-490-9091
Mailing Address - Fax:877-259-0981
Practice Address - Street 1:2950 THOUSAND OAKS DR STE 23
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78247-3347
Practice Address - Country:US
Practice Address - Phone:210-490-9091
Practice Address - Fax:877-259-0981
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-12
Last Update Date:2021-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX4343TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty