Provider Demographics
NPI:1720251853
Name:MICHAEL D CONTE ODPC
Entity Type:Organization
Organization Name:MICHAEL D CONTE ODPC
Other - Org Name:AZLE VISION SOURCE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRACTICE ADMIN.
Authorized Official - Prefix:MRS
Authorized Official - First Name:BETTY
Authorized Official - Middle Name:
Authorized Official - Last Name:MCWILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:ABOC
Authorized Official - Phone:817-626-4441
Mailing Address - Street 1:601 NORTHWEST PKWY
Mailing Address - Street 2:SUITE B
Mailing Address - City:AZLE
Mailing Address - State:TX
Mailing Address - Zip Code:76020-2930
Mailing Address - Country:US
Mailing Address - Phone:817-444-1717
Mailing Address - Fax:817-270-5100
Practice Address - Street 1:601 NORTHWEST PKWY
Practice Address - Street 2:SUITE B
Practice Address - City:AZLE
Practice Address - State:TX
Practice Address - Zip Code:76020-2930
Practice Address - Country:US
Practice Address - Phone:817-444-1717
Practice Address - Fax:817-270-5100
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MICHAEL D CONTE ODPC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-04-09
Last Update Date:2008-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX3120TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1417951179OtherNPI
TX8A3015OtherMEDICARE
TX1417951179OtherNPI
TX5125280003Medicare NSC
TXT12758Medicare PIN