Provider Demographics
NPI:1740466697
Name:MAIN ST. OPTICAL
Entity type:Organization
Organization Name:MAIN ST. OPTICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:K
Authorized Official - Last Name:BAUGH
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:903-465-9214
Mailing Address - Street 1:307 W. MAIN ST.
Mailing Address - Street 2:
Mailing Address - City:DENISON
Mailing Address - State:TX
Mailing Address - Zip Code:75020-3124
Mailing Address - Country:US
Mailing Address - Phone:903-465-9214
Mailing Address - Fax:903-463-6919
Practice Address - Street 1:307 W. MAIN ST.
Practice Address - Street 2:
Practice Address - City:DENISON
Practice Address - State:TX
Practice Address - Zip Code:75020-3124
Practice Address - Country:US
Practice Address - Phone:903-465-9214
Practice Address - Fax:903-463-6919
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-10
Last Update Date:2008-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX3551T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00E68GMedicare PIN
TXT12116Medicare UPIN