Provider Demographics
NPI:1376620716
Name:LEAGUE CITY TEXAS STATE OPTICAL PA
Entity Type:Organization
Organization Name:LEAGUE CITY TEXAS STATE OPTICAL PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:R
Authorized Official - Last Name:FINGOLD
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:281-535-8876
Mailing Address - Street 1:2700 MARINA BAY DR STE A
Mailing Address - Street 2:
Mailing Address - City:LEAGUE CITY
Mailing Address - State:TX
Mailing Address - Zip Code:77573-2480
Mailing Address - Country:US
Mailing Address - Phone:281-535-8876
Mailing Address - Fax:
Practice Address - Street 1:2700 MARINA BAY DR STE A
Practice Address - Street 2:
Practice Address - City:LEAGUE CITY
Practice Address - State:TX
Practice Address - Zip Code:77573-2480
Practice Address - Country:US
Practice Address - Phone:281-535-8876
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2022-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX3270TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty