Provider Demographics
NPI:1003892597
Name:RETINA AND VITREOUS OF TEXAS PLLC
Entity type:Organization
Organization Name:RETINA AND VITREOUS OF TEXAS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:A
Authorized Official - Last Name:KHAWLY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:713-799-9975
Mailing Address - Street 1:6565 WEST LOOP S STE 400
Mailing Address - Street 2:
Mailing Address - City:BELLAIRE
Mailing Address - State:TX
Mailing Address - Zip Code:77401-3510
Mailing Address - Country:US
Mailing Address - Phone:713-799-9975
Mailing Address - Fax:713-799-1095
Practice Address - Street 1:6565 WEST LOOP S STE 400
Practice Address - Street 2:
Practice Address - City:BELLAIRE
Practice Address - State:TX
Practice Address - Zip Code:77401-3510
Practice Address - Country:US
Practice Address - Phone:713-799-9975
Practice Address - Fax:713-799-1095
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-16
Last Update Date:2024-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0950032 02Medicaid
TX0044BMMedicare ID - Type Unspecified