Provider Demographics
NPI:1366631582
Name:BRUCE WICK OD PHD PA
Entity Type:Organization
Organization Name:BRUCE WICK OD PHD PA
Other - Org Name:VISION SOURCE MISSION BEND LLP
Other - Org Type:Other Name
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:
Authorized Official - Last Name:WICK
Authorized Official - Suffix:
Authorized Official - Credentials:OD PHD
Authorized Official - Phone:281-933-3446
Mailing Address - Street 1:13615 BELLAIRE BLVD
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77083-1714
Mailing Address - Country:US
Mailing Address - Phone:281-933-3446
Mailing Address - Fax:281-933-6865
Practice Address - Street 1:13615 BELLAIRE BLVD
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77083-1714
Practice Address - Country:US
Practice Address - Phone:281-933-3446
Practice Address - Fax:281-933-6865
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-24
Last Update Date:2008-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX4743680001OtherGIGNA GOV SERVICES NUMBER
TX4743680001OtherGIGNA GOV SERVICES NUMBER
TX00E94WMedicare PIN