Provider Demographics
NPI:1831198548
Name:PALYS, AGNES LORRAINE (OD)
Entity type:Individual
Prefix:DR
First Name:AGNES
Middle Name:LORRAINE
Last Name:PALYS
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4930 EVERS RD
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78228-2118
Mailing Address - Country:US
Mailing Address - Phone:210-431-0366
Mailing Address - Fax:210-431-0379
Practice Address - Street 1:4930 EVERS RD
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78228-2118
Practice Address - Country:US
Practice Address - Phone:210-431-0366
Practice Address - Fax:210-431-0379
Is Sole Proprietor?:No
Enumeration Date:2005-07-15
Last Update Date:2015-04-06
Deactivation Date:2006-03-18
Deactivation Code:
Reactivation Date:2006-03-24
Provider Licenses
StateLicense IDTaxonomies
TX2863TG152W00000X, 152WC0802X, 152WL0500X, 152WS0006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152WL0500XEye and Vision Services ProvidersOptometristLow Vision Rehabilitation
No152WS0006XEye and Vision Services ProvidersOptometristSports Vision
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX121616003Medicaid
TX0289900001Medicare NSC
TX80193EMedicare PIN
TXT15151Medicare UPIN