Provider Demographics
NPI:1790767309
Name:CELICO, BRIAN MICHAEL (OD)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:MICHAEL
Last Name:CELICO
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7150 GREENVILLE AVE
Mailing Address - Street 2:SUITE 305
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75231-5185
Mailing Address - Country:US
Mailing Address - Phone:214-265-1111
Mailing Address - Fax:214-265-1189
Practice Address - Street 1:7150 GREENVILLE AVE
Practice Address - Street 2:SUITE 305
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75231-5185
Practice Address - Country:US
Practice Address - Phone:214-265-1111
Practice Address - Fax:214-265-1189
Is Sole Proprietor?:No
Enumeration Date:2005-11-18
Last Update Date:2016-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX3455TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX019461501Medicaid
U55307Medicare UPIN
TX00E69UMedicare ID - Type Unspecified