Provider Demographics
NPI:1700334794
Name:EYE DOCTORS OF SOUTH TEXAS, PLLC
Entity Type:Organization
Organization Name:EYE DOCTORS OF SOUTH TEXAS, PLLC
Other - Org Name:VISTA VISION
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:TONI
Authorized Official - Middle Name:WYNN
Authorized Official - Last Name:RACOMA
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:609-312-1115
Mailing Address - Street 1:427 N LOOP 1604 W
Mailing Address - Street 2:STE 203
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78232-1033
Mailing Address - Country:US
Mailing Address - Phone:210-960-5494
Mailing Address - Fax:210-960-2261
Practice Address - Street 1:427 N LOOP 1604 W
Practice Address - Street 2:SUITE 203
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78232-1033
Practice Address - Country:US
Practice Address - Phone:210-960-5494
Practice Address - Fax:210-960-2261
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-19
Last Update Date:2016-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX8129TG152W00000X, 152WC0802X, 152WL0500X, 152WP0200X, 152WS0006X, 152WV0400X, 152WX0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact ManagementGroup - Multi-Specialty
No152WL0500XEye and Vision Services ProvidersOptometristLow Vision RehabilitationGroup - Multi-Specialty
No152WP0200XEye and Vision Services ProvidersOptometristPediatricsGroup - Multi-Specialty
No152WS0006XEye and Vision Services ProvidersOptometristSports VisionGroup - Multi-Specialty
No152WV0400XEye and Vision Services ProvidersOptometristVision TherapyGroup - Multi-Specialty
No152WX0102XEye and Vision Services ProvidersOptometristOccupational VisionGroup - Multi-Specialty