Provider Demographics
NPI:1912189374
Name:CEDAR PARK EYE CARE PA
Entity Type:Organization
Organization Name:CEDAR PARK EYE CARE PA
Other - Org Name:CEDAR PARK EYE CARE
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DENNIS
Authorized Official - Middle Name:ROLAND
Authorized Official - Last Name:MCCARTY
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:512-249-0808
Mailing Address - Street 1:210 N LAKELINE BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:CEDAR PARK
Mailing Address - State:TX
Mailing Address - Zip Code:78613-2088
Mailing Address - Country:US
Mailing Address - Phone:512-249-0808
Mailing Address - Fax:512-249-0828
Practice Address - Street 1:210 N LAKELINE BLVD STE 100
Practice Address - Street 2:
Practice Address - City:CEDAR PARK
Practice Address - State:TX
Practice Address - Zip Code:78613-2088
Practice Address - Country:US
Practice Address - Phone:512-249-0808
Practice Address - Fax:512-249-0828
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-28
Last Update Date:2019-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX5874TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
U81322Medicare UPIN
00400WMedicare PIN