Basic Information
| Provider Information | |||||||||
| NPI: | 1245336718 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | OPHTHALMIC PARTNERS, PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 911791 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 753911791 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9727911224 | ||||||||
| FaxNumber: | 8775945434 | ||||||||
| Practice Location | |||||||||
| Address1: | 2625 BOLTON BOONE DR | ||||||||
| Address2: | |||||||||
| City: | DESOTO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 751152011 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9722831516 | ||||||||
| FaxNumber: | 9722831448 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/15/2006 | ||||||||
| LastUpdateDate: | 03/18/2008 | ||||||||
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| AuthorizedOfficialLastName: | HENDRICKS | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8173322020 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | 207W00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Ophthalmology |
ID Information
| ID | Type | State | Issuer | Description | 1373466 10 | 05 | TX | MEDICAID |