Provider Demographics
NPI:1629139324
Name:NORTH TEXAS OPHTHALMIC PLASTIC SURGERY, PLLC
Entity Type:Organization
Organization Name:NORTH TEXAS OPHTHALMIC PLASTIC SURGERY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:LACY
Authorized Official - Middle Name:
Authorized Official - Last Name:FLORES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-566-1500
Mailing Address - Street 1:800 8TH AVE
Mailing Address - Street 2:STE 330
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-2601
Mailing Address - Country:US
Mailing Address - Phone:817-566-1500
Mailing Address - Fax:682-432-0763
Practice Address - Street 1:800 8TH AVE
Practice Address - Street 2:STE 330
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-2601
Practice Address - Country:US
Practice Address - Phone:817-566-1500
Practice Address - Fax:682-432-0763
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-13
Last Update Date:2015-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0A5539Medicare PIN
TX0A5540Medicare PIN
TX0A5538Medicare PIN