Provider Demographics
NPI:1275226656
Name:SEREBRO, SLAVA A
Entity Type:Individual
Prefix:
First Name:SLAVA
Middle Name:A
Last Name:SEREBRO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6300 OAKMONT BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76132-2807
Mailing Address - Country:US
Mailing Address - Phone:817-263-0185
Mailing Address - Fax:817-263-4281
Practice Address - Street 1:6300 OAKMONT BLVD
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76132-2807
Practice Address - Country:US
Practice Address - Phone:817-263-0185
Practice Address - Fax:817-263-4281
Is Sole Proprietor?:No
Enumeration Date:2023-05-31
Last Update Date:2023-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX003137156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician