Provider Demographics
NPI:1437330065
Name:COLLEGE STATION OPTICAL, PC
Entity Type:Organization
Organization Name:COLLEGE STATION OPTICAL, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:THERAPEUTIC OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:R.
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:MAGGS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:979-764-0009
Mailing Address - Street 1:2414 TEXAS AVE S STE A
Mailing Address - Street 2:
Mailing Address - City:COLLEGE STATION
Mailing Address - State:TX
Mailing Address - Zip Code:77840-4145
Mailing Address - Country:US
Mailing Address - Phone:979-764-0009
Mailing Address - Fax:979-764-7715
Practice Address - Street 1:2414 TEXAS AVE S STE A
Practice Address - Street 2:
Practice Address - City:COLLEGE STATION
Practice Address - State:TX
Practice Address - Zip Code:77840-4145
Practice Address - Country:US
Practice Address - Phone:979-764-0009
Practice Address - Fax:979-764-7715
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-26
Last Update Date:2008-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX02481T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00E07FOtherBCBS OF TX
TX00E07FOtherBCBS OF TX
TX00459XMedicare PIN