Provider Demographics
NPI:1396819769
Name:SOUTH TEXAS EYE CONSULTANTS, PLLC
Entity Type:Organization
Organization Name:SOUTH TEXAS EYE CONSULTANTS, PLLC
Other - Org Name:SOUTH TEXAS EYE CONSULTANTS
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:RUSSELL
Authorized Official - Last Name:DIETZE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:361-992-9400
Mailing Address - Street 1:5402 S. STAPLES
Mailing Address - Street 2:SUITE 100
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78411-4656
Mailing Address - Country:US
Mailing Address - Phone:361-992-9400
Mailing Address - Fax:361-992-8295
Practice Address - Street 1:5402 S. STAPLES
Practice Address - Street 2:SUITE 100
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78411-4656
Practice Address - Country:US
Practice Address - Phone:361-992-9400
Practice Address - Fax:361-992-8295
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-20
Last Update Date:2009-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX084894701Medicaid
TX00R76WMedicare ID - Type Unspecified