Provider Demographics
NPI:1720011497
Name:BERKELEY EYE INSTITUTE, PLLC
Entity Type:Organization
Organization Name:BERKELEY EYE INSTITUTE, PLLC
Other - Org Name:BERKELEY EYE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:F
Authorized Official - Last Name:MICHELETTI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:281-348-4615
Mailing Address - Street 1:21502 MERCHANTS WAY STE A
Mailing Address - Street 2:
Mailing Address - City:KATY
Mailing Address - State:TX
Mailing Address - Zip Code:77449-2515
Mailing Address - Country:US
Mailing Address - Phone:281-944-2232
Mailing Address - Fax:281-944-2290
Practice Address - Street 1:22741 PROFESSIONAL DRIVE
Practice Address - Street 2:
Practice Address - City:KINGWOOD
Practice Address - State:TX
Practice Address - Zip Code:77339-6005
Practice Address - Country:US
Practice Address - Phone:281-319-4334
Practice Address - Fax:281-319-4855
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-08
Last Update Date:2023-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
No152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
No332H00000XSuppliersEyewear SupplierGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX158574701Medicaid
TX4894760008OtherPALMETTO GBA
TX0072KDOtherBLUE CROSS BLUE SHIELD
TX00309VMedicare ID - Type Unspecified
TX4894760008Medicare NSC
TX0072KDOtherBLUE CROSS BLUE SHIELD