Provider Demographics
NPI:1932343167
Name:MONTY BANKS OD PA
Entity Type:Organization
Organization Name:MONTY BANKS OD PA
Other - Org Name:TEXAS STATE OPTICAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MONTY
Authorized Official - Middle Name:S
Authorized Official - Last Name:BANKS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:254-968-4133
Mailing Address - Street 1:101 N DALE AVE
Mailing Address - Street 2:
Mailing Address - City:STEPHENVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:76401-2832
Mailing Address - Country:US
Mailing Address - Phone:254-968-4133
Mailing Address - Fax:254-968-5631
Practice Address - Street 1:101 N DALE AVE
Practice Address - Street 2:
Practice Address - City:STEPHENVILLE
Practice Address - State:TX
Practice Address - Zip Code:76401-2832
Practice Address - Country:US
Practice Address - Phone:254-968-4133
Practice Address - Fax:254-968-5631
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-01
Last Update Date:2009-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX3115TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXG000E50E0Medicaid
TXE5OEMedicare PIN
TXG000E50E0Medicaid