Provider Demographics
NPI:1457334039
Name:MINADEO EYE CENTER PLLC
Entity Type:Organization
Organization Name:MINADEO EYE CENTER PLLC
Other - Org Name:MINADEO EYE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:ELLISTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:720-273-7449
Mailing Address - Street 1:3900 E MEXICO AVE STE 102
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80210-3941
Mailing Address - Country:US
Mailing Address - Phone:303-800-2078
Mailing Address - Fax:303-800-2078
Practice Address - Street 1:2007 N JEFFERSON AVE
Practice Address - Street 2:
Practice Address - City:MOUNT PLEASANT
Practice Address - State:TX
Practice Address - Zip Code:75455-2336
Practice Address - Country:US
Practice Address - Phone:903-572-6655
Practice Address - Fax:903-572-0213
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-28
Last Update Date:2020-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX084926701Medicaid
TX00R84ZMedicare PIN