Provider Demographics
NPI:1912019076
Name:VISION PLAZA PA
Entity Type:Organization
Organization Name:VISION PLAZA PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ANDRE
Authorized Official - Middle Name:
Authorized Official - Last Name:LE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:817-295-9696
Mailing Address - Street 1:116 E ELLISON ST STE C
Mailing Address - Street 2:
Mailing Address - City:BURLESON
Mailing Address - State:TX
Mailing Address - Zip Code:76028-4286
Mailing Address - Country:US
Mailing Address - Phone:214-998-0934
Mailing Address - Fax:817-295-9313
Practice Address - Street 1:116 E ELLISON ST STE C
Practice Address - Street 2:
Practice Address - City:BURLESON
Practice Address - State:TX
Practice Address - Zip Code:76028-4286
Practice Address - Country:US
Practice Address - Phone:817-295-9696
Practice Address - Fax:817-295-9313
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2022-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX6555TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX177115601Medicaid