Provider Demographics
NPI:1578673026
Name:RETINA INSTITUTE OF TEXAS PA
Entity Type:Organization
Organization Name:RETINA INSTITUTE OF TEXAS PA
Other - Org Name:TAYLOR WINSLOW SYRQUIN & KOZIELEC, P.A.
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:F
Authorized Official - Last Name:KOZIELEC
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:214-521-1153
Mailing Address - Street 1:3414 OAK GROVE AVE
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75204-2375
Mailing Address - Country:US
Mailing Address - Phone:214-521-1153
Mailing Address - Fax:214-219-3651
Practice Address - Street 1:3414 OAK GROVE AVE
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75204-2375
Practice Address - Country:US
Practice Address - Phone:214-521-1153
Practice Address - Fax:214-219-3651
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:RETINA INSTITUTE OF TEXAS PA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-08-30
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NA207W00000X
207WX0107X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207WX0107XAllopathic & Osteopathic PhysiciansOphthalmologyRetina SpecialistGroup - Single Specialty
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200052590AMedicaid
AR168301002Medicaid
TXCJ5857OtherRR MEDICARE
TX156683801Medicaid
TX00T587OtherBCBS
TX00474RMedicare PIN