Provider Demographics
NPI:1750657037
Name:MEDICAL CENTER OPHTHALMOLOGY ASSOCIATES
Entity Type:Organization
Organization Name:MEDICAL CENTER OPHTHALMOLOGY ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:DALE
Authorized Official - Middle Name:T
Authorized Official - Last Name:CHRISTIANSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:210-697-2007
Mailing Address - Street 1:PO BOX 1358
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78295-1358
Mailing Address - Country:US
Mailing Address - Phone:210-697-2020
Mailing Address - Fax:
Practice Address - Street 1:315 N SAN SABA STE 970
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78207-3100
Practice Address - Country:US
Practice Address - Phone:210-697-2020
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-30
Last Update Date:2012-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
No152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00HV39OtherMEDICARE GRP B
TX083052302Medicaid
TX0313550001Medicare NSC