Provider Demographics
NPI:1801966528
Name:SOUTHLAKE EYE ASSOCIATES, PA
Entity type:Organization
Organization Name:SOUTHLAKE EYE ASSOCIATES, PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:B
Authorized Official - Last Name:KLOESEL
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:817-562-2101
Mailing Address - Street 1:101 RIVER OAKS DR
Mailing Address - Street 2:STE 100
Mailing Address - City:SOUTHLAKE
Mailing Address - State:TX
Mailing Address - Zip Code:76092
Mailing Address - Country:US
Mailing Address - Phone:817-562-2101
Mailing Address - Fax:817-562-2201
Practice Address - Street 1:101 RIVER OAKS DR
Practice Address - Street 2:STE 100
Practice Address - City:SOUTHLAKE
Practice Address - State:TX
Practice Address - Zip Code:76092
Practice Address - Country:US
Practice Address - Phone:817-562-2101
Practice Address - Fax:817-562-2201
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-09
Last Update Date:2018-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX4107TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX=========OtherEIN
TX4717500001Medicare ID - Type UnspecifiedMEDICARE PALMETTO
TX00Z898Medicare PIN