Provider Demographics
NPI:1194859769
Name:VANTAGE VISION P.C.
Entity Type:Organization
Organization Name:VANTAGE VISION P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DAT
Authorized Official - Middle Name:
Authorized Official - Last Name:LY
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:903-581-2426
Mailing Address - Street 1:4601 S BROADWAY AVE
Mailing Address - Street 2:F22
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75703-1307
Mailing Address - Country:US
Mailing Address - Phone:903-581-2426
Mailing Address - Fax:
Practice Address - Street 1:4601 S BROADWAY AVE
Practice Address - Street 2:F22
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75703-1307
Practice Address - Country:US
Practice Address - Phone:903-581-2426
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX6516 T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00W169Medicare ID - Type Unspecified