Provider Demographics
NPI:1265531818
Name:EAST TEXAS EYE CENTER PA
Entity type:Organization
Organization Name:EAST TEXAS EYE CENTER PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KIM
Authorized Official - Middle Name:RAY
Authorized Official - Last Name:SHRUM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:281-812-4000
Mailing Address - Street 1:18700 W LAKE HOUSTON PKWY
Mailing Address - Street 2:SUITE B101
Mailing Address - City:HUMBLE
Mailing Address - State:TX
Mailing Address - Zip Code:77346-3349
Mailing Address - Country:US
Mailing Address - Phone:281-812-4000
Mailing Address - Fax:281-812-3331
Practice Address - Street 1:18700 W LAKE HOUSTON PKWY
Practice Address - Street 2:SUITE B101
Practice Address - City:HUMBLE
Practice Address - State:TX
Practice Address - Zip Code:77346-3349
Practice Address - Country:US
Practice Address - Phone:281-812-4000
Practice Address - Fax:281-812-3331
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-21
Last Update Date:2014-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
No152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX24940OtherOPTICARE
TX145198104Medicaid
TX606334OtherCORE SOURCE/HEALTH LINK
TX7114117OtherAETNA
TX452026OtherNVA
TX55951OtherSAFEGUARD
TXDE8958OtherMEDICARE RAILROAD
TX0084GSOtherBLUECROSS BLUESHIELD GRP
TX20459OtherUTMB CHIPS
TX5248990OtherCCN / FIRST HEALTH
TX975250OtherONE HEALTH PLAN
TX5248990OtherCCN / FIRST HEALTH
TX24940OtherOPTICARE