Provider Demographics
NPI:1649261322
Name:VLASAK, MARIE ELAINE (OD)
Entity type:Individual
Prefix:DR
First Name:MARIE
Middle Name:ELAINE
Last Name:VLASAK
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:M.
Other - Middle Name:ELAINE
Other - Last Name:VLASAK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OD
Mailing Address - Street 1:17503 LA CANTERA PKWY
Mailing Address - Street 2:SUITE 115
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78257-8207
Mailing Address - Country:US
Mailing Address - Phone:210-699-3937
Mailing Address - Fax:210-200-6339
Practice Address - Street 1:17503 LA CANTERA PKWY
Practice Address - Street 2:SUITE 115
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78257-8207
Practice Address - Country:US
Practice Address - Phone:210-699-3937
Practice Address - Fax:210-200-6339
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-02
Last Update Date:2011-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX5039TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX093342603Medicaid
TX093342603Medicaid