Provider Demographics
NPI:1306002407
Name:BERKELEY EYE INSTITUTE, PLLC
Entity Type:Organization
Organization Name:BERKELEY EYE INSTITUTE, PLLC
Other - Org Name:BERKELEY EYE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:F
Authorized Official - Last Name:MICHELETTI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:281-348-4615
Mailing Address - Street 1:143 VISION PARK BLVD
Mailing Address - Street 2:
Mailing Address - City:SHENANDOAH
Mailing Address - State:TX
Mailing Address - Zip Code:77384-3001
Mailing Address - Country:US
Mailing Address - Phone:281-363-3443
Mailing Address - Fax:936-271-1351
Practice Address - Street 1:143 VISION PARK BLVD
Practice Address - Street 2:
Practice Address - City:SHENANDOAH
Practice Address - State:TX
Practice Address - Zip Code:77384-3001
Practice Address - Country:US
Practice Address - Phone:281-363-3443
Practice Address - Fax:936-271-1351
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-29
Last Update Date:2023-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
No152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
No332H00000XSuppliersEyewear SupplierGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0072KDOtherBLUE CROSS BLUE SHIELD
TX158559801Medicaid
TX00312VMedicare PIN
TX0072KDOtherBLUE CROSS BLUE SHIELD