Provider Demographics
NPI:1518415330
Name:MOMPREMIER EYE INSTITUTE, PLLC
Entity Type:Organization
Organization Name:MOMPREMIER EYE INSTITUTE, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:MIKELSON
Authorized Official - Middle Name:
Authorized Official - Last Name:MOMPREMIER
Authorized Official - Suffix:
Authorized Official - Credentials:MD, FACS
Authorized Official - Phone:469-687-5664
Mailing Address - Street 1:1510 N HAMPTON RD
Mailing Address - Street 2:SUITE 290
Mailing Address - City:DESOTO
Mailing Address - State:TX
Mailing Address - Zip Code:75115-8300
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1510 N HAMPTON RD
Practice Address - Street 2:SUITE 290
Practice Address - City:DESOTO
Practice Address - State:TX
Practice Address - Zip Code:75115-8300
Practice Address - Country:US
Practice Address - Phone:954-302-7657
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-21
Last Update Date:2018-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXP7164207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX323540001Medicaid