Provider Demographics
NPI:1275715963
Name:TEXAS STATE OPTICAL OF BRYAN PC
Entity Type:Organization
Organization Name:TEXAS STATE OPTICAL OF BRYAN PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:GERALD
Authorized Official - Middle Name:D
Authorized Official - Last Name:PHILLIPS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:979-731-8446
Mailing Address - Street 1:3030 E 29TH ST
Mailing Address - Street 2:SUITE 106
Mailing Address - City:BRYAN
Mailing Address - State:TX
Mailing Address - Zip Code:77802-2757
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3030 E 29TH ST
Practice Address - Street 2:SUITE 106
Practice Address - City:BRYAN
Practice Address - State:TX
Practice Address - Zip Code:77802-2757
Practice Address - Country:US
Practice Address - Phone:979-731-8446
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-04
Last Update Date:2008-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX16110OtherSPECTERA
TX6271OtherAVESIS
TX80323EOtherBLUE CROSS BLUE SHIELD
TX902303OtherBLOCK VISION
TX112311903Medicaid
TX16258OtherSCOTT & WHITE
TXTX2145OtherEYEMED
TX59496OtherSAFEGUARD
TX16258OtherSCOTT & WHITE
TX59496OtherSAFEGUARD
TX410000907Medicare PIN