Provider Demographics
NPI:1558827030
Name:BALA, MODESTO MACOGAY III (OD)
Entity Type:Individual
Prefix:
First Name:MODESTO
Middle Name:MACOGAY
Last Name:BALA
Suffix:III
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5050 SAM HOUSTON AVE APT 518
Mailing Address - Street 2:
Mailing Address - City:HUNTSVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:77340-6674
Mailing Address - Country:US
Mailing Address - Phone:808-319-9384
Mailing Address - Fax:
Practice Address - Street 1:229 IH 45 S STE H
Practice Address - Street 2:
Practice Address - City:HUNTSVILLE
Practice Address - State:TX
Practice Address - Zip Code:77340-4988
Practice Address - Country:US
Practice Address - Phone:936-755-7740
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-20
Last Update Date:2022-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIOD-901152W00000X
TX9803152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist