Provider Demographics
NPI:1932640885
Name:GEORGOPOULOS, ELIAS L (OD)
Entity Type:Individual
Prefix:DR
First Name:ELIAS
Middle Name:L
Last Name:GEORGOPOULOS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:ELIAS
Other - Middle Name:
Other - Last Name:GEORGOPOULOS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OD
Mailing Address - Street 1:11820 WILSHIRE AVE NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87122-1578
Mailing Address - Country:US
Mailing Address - Phone:505-363-5276
Mailing Address - Fax:
Practice Address - Street 1:2959 S BUCKNER BLVD
Practice Address - Street 2:STE 700
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75227-6945
Practice Address - Country:US
Practice Address - Phone:214-239-2176
Practice Address - Fax:214-239-2177
Is Sole Proprietor?:No
Enumeration Date:2017-03-12
Last Update Date:2022-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10234692-9934152W00000X
UT10234692-8908152W00000X
TX9126T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX369734401Medicaid
TX301821003Medicaid
TX301821005Medicaid
TX369734402Medicaid