Provider Demographics
NPI:1659663292
Name:EYEDENTITY, P.A.
Entity Type:Organization
Organization Name:EYEDENTITY, P.A.
Other - Org Name:EYEDEAL VISION
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:
Authorized Official - Last Name:THAM
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:713-526-1718
Mailing Address - Street 1:2519 UNIVERSITY BLVD
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77005-3228
Mailing Address - Country:US
Mailing Address - Phone:713-526-1718
Mailing Address - Fax:713-526-3137
Practice Address - Street 1:3506 HIGHWAY 6 S
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77082-4204
Practice Address - Country:US
Practice Address - Phone:713-526-1718
Practice Address - Fax:713-526-3137
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-13
Last Update Date:2011-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX6346T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty