Provider Demographics
NPI:1477640076
Name:PLAZA OPTICAL
Entity Type:Organization
Organization Name:PLAZA OPTICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTHOLMOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:K
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:281-348-3385
Mailing Address - Street 1:22999 HWY 59 NORTH
Mailing Address - Street 2:SUITE 124
Mailing Address - City:KINGWOOD
Mailing Address - State:TX
Mailing Address - Zip Code:77339-4412
Mailing Address - Country:US
Mailing Address - Phone:281-348-3385
Mailing Address - Fax:281-348-3386
Practice Address - Street 1:22999 HWY 59 NORTH
Practice Address - Street 2:SUITE 124
Practice Address - City:KINGWOOD
Practice Address - State:TX
Practice Address - Zip Code:77339-4412
Practice Address - Country:US
Practice Address - Phone:281-348-3385
Practice Address - Fax:281-348-3386
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0214270001Medicare ID - Type Unspecified