Provider Demographics
NPI:1366453920
Name:ANGELINA OPTOMETRIC ASSOCIATES
Entity Type:Organization
Organization Name:ANGELINA OPTOMETRIC ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:W
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:JR
Authorized Official - Credentials:OD
Authorized Official - Phone:936-637-2020
Mailing Address - Street 1:2801 S JOHN REDDITT DR
Mailing Address - Street 2:
Mailing Address - City:LUFKIN
Mailing Address - State:TX
Mailing Address - Zip Code:75904-5666
Mailing Address - Country:US
Mailing Address - Phone:936-637-2020
Mailing Address - Fax:936-634-4911
Practice Address - Street 1:2801 S JOHN REDDITT DR
Practice Address - Street 2:
Practice Address - City:LUFKIN
Practice Address - State:TX
Practice Address - Zip Code:75904-5666
Practice Address - Country:US
Practice Address - Phone:936-637-2020
Practice Address - Fax:936-634-4911
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-10
Last Update Date:2018-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
No332H00000XSuppliersEyewear SupplierGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00B01SOtherMEDICARE
TX093682501Medicaid
TX00B01SOtherMEDICARE