Provider Demographics
NPI:1346787157
Name:ALLIANCE RETINA OF TEXAS, PLLC
Entity Type:Organization
Organization Name:ALLIANCE RETINA OF TEXAS, PLLC
Other - Org Name:ALLIANCE RETINA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:KIM-BINH
Authorized Official - Middle Name:THI
Authorized Official - Last Name:MAI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:817-617-7678
Mailing Address - Street 1:3824 N TARRANT PKWY STE 310
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76244-5431
Mailing Address - Country:US
Mailing Address - Phone:817-617-7678
Mailing Address - Fax:817-617-7681
Practice Address - Street 1:3824 N TARRANT PKWY STE 310
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76244-5431
Practice Address - Country:US
Practice Address - Phone:817-617-7678
Practice Address - Fax:817-617-7681
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-31
Last Update Date:2020-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXQ4189207WX0107X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207WX0107XAllopathic & Osteopathic PhysiciansOphthalmologyRetina SpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX568495Medicare PIN