Provider Demographics
NPI:1457385551
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:DR
Authorized Official - First Name:K
Authorized Official - Middle Name:RAY
Authorized Official - Last Name:SHRUM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:281-659-2020
Mailing Address - Street 1:18700 W LAKE HOUSTON PKWY
Mailing Address - Street 2:STE 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 1:901 E HOUSTON ST
Practice Address - Street 2:STE B
Practice Address - City:CLEVELAND
Practice Address - State:TX
Practice Address - Zip Code:77327-4602
Practice Address - Country:US
Practice Address - Phone:281-659-2020
Practice Address - Fax:281-659-2030
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-11
Last Update Date:2015-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX02830TG152W00000X
TXL2649207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
No152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
918304OtherBLOCK VISION
21210202328OtherBEECH STREET
TXDE8958OtherMEDICARE RAILROAD
TX0084GSOtherBLUE CROSS BLUE SHIELD
180044544OtherMEDICARE RAILROAD
7114117OtherAETNA
TX145198102Medicaid
975250OtherONE HEALTH PLAN
4119904OtherCIGNA
5248990OtherFIRST HEALTH
TX145198103Medicaid
21210202328OtherBEECHSTREET
5248990OtherCCN
TX145198102Medicaid
21210202328OtherBEECHSTREET