Provider Demographics
NPI:1972657773
Name:DEHAVEN EYE CLINIC PA
Entity Type:Organization
Organization Name:DEHAVEN EYE CLINIC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FINANCIAL SERVICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:GINA
Authorized Official - Middle Name:
Authorized Official - Last Name:LOWNDES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:903-595-7510
Mailing Address - Street 1:PO BOX 130639
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75713-0639
Mailing Address - Country:US
Mailing Address - Phone:903-595-4144
Mailing Address - Fax:903-526-5491
Practice Address - Street 1:1424 E FRONT ST
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75702-8501
Practice Address - Country:US
Practice Address - Phone:903-595-4144
Practice Address - Fax:903-526-5491
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-22
Last Update Date:2017-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX120728405Medicaid
TX00C25JOtherBLUE CROSS BLUE SHIELD
TXCP3305Medicare PIN
TX00C25JMedicare PIN