Provider Demographics
NPI:1457540221
Name:AUSTIN EYE CLINIC ASSOCIATION
Entity Type:Organization
Organization Name:AUSTIN EYE CLINIC ASSOCIATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHANNON
Authorized Official - Middle Name:
Authorized Official - Last Name:WONG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:512-250-2020
Mailing Address - Street 1:11901 JOLLYVILLE RD
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78759-2303
Mailing Address - Country:US
Mailing Address - Phone:512-250-2020
Mailing Address - Fax:512-250-2612
Practice Address - Street 1:2700 BEE CAVES RD
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78746-5675
Practice Address - Country:US
Practice Address - Phone:512-250-2020
Practice Address - Fax:512-250-2612
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-17
Last Update Date:2020-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00K61VOtherBCBS
TX083533201Medicaid