Provider Demographics
NPI:1982720637
Name:TEXAS STATE OPTICAL
Entity Type:Organization
Organization Name:TEXAS STATE OPTICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:E
Authorized Official - Last Name:SIEGEL
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:713-681-2467
Mailing Address - Street 1:564 NORTHWEST MALL
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77092-8544
Mailing Address - Country:US
Mailing Address - Phone:713-681-2467
Mailing Address - Fax:713-681-0537
Practice Address - Street 1:564 NORTHWEST MALL
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77092-8544
Practice Address - Country:US
Practice Address - Phone:713-681-2467
Practice Address - Fax:713-681-0537
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-22
Last Update Date:2008-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2141152W00000X, 332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
No332H00000XSuppliersEyewear SupplierGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXG000E92A2Medicaid
TX6306OtherAVESIS
TX902815OtherBLOCK VISION
TX16114OtherSPECTERA
TX143837OtherEYE MED
TXQMP000003344370OtherMOLINA
TX5595OtherSAFEGAURD
TX019563801OtherMEDICAID
TX=========OtherSUPERIOR VISION
TX143837OtherEYE MED
TX=========OtherCOMP BENEFITS
TXQMP000003344370OtherMOLINA
TXOOE92AMedicare PIN