Provider Demographics
NPI:1134392293
Name:BRIAN M. CELICO, OD PA
Entity type:Organization
Organization Name:BRIAN M. CELICO, OD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:M
Authorized Official - Last Name:CELICO
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:214-265-1111
Mailing Address - Street 1:7150 GREENVILLE AVE
Mailing Address - Street 2:SUITE 305
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75231-5185
Mailing Address - Country:US
Mailing Address - Phone:214-265-1111
Mailing Address - Fax:
Practice Address - Street 1:7150 GREENVILLE AVE
Practice Address - Street 2:SUITE 305
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75231-5185
Practice Address - Country:US
Practice Address - Phone:214-265-1111
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-10
Last Update Date:2012-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX3455 TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00E69UOtherBLUE CROSS OF TEXAS
TX0194615-01Medicaid
TX=========OtherCIGNA
TX00E69UOtherBLUE CROSS OF TEXAS
TX=========OtherAETNA
TX=========OtherUNITED HEALTHCARE
TX=========OtherTRICARE
TX=========OtherSECURE HORIZONS