Provider Demographics
NPI:1518993658
Name:ADVANCED GLAUCOMA DIAGNOSTIC AND TREATMENT CENTER, P.A.
Entity Type:Organization
Organization Name:ADVANCED GLAUCOMA DIAGNOSTIC AND TREATMENT CENTER, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:
Authorized Official - Last Name:GOODE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-332-4005
Mailing Address - Street 1:200 W MAGNOLIA AVE
Mailing Address - Street 2:100
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-7644
Mailing Address - Country:US
Mailing Address - Phone:817-332-4005
Mailing Address - Fax:817-332-4039
Practice Address - Street 1:200 W MAGNOLIA AVE
Practice Address - Street 2:100
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-7644
Practice Address - Country:US
Practice Address - Phone:817-332-4005
Practice Address - Fax:817-332-4039
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00J13HMedicare ID - Type Unspecified