Basic Information
| Provider Information | |||||||||
| NPI: | 1568458792 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BUBELA | ||||||||
| FirstName: | BERT | ||||||||
| MiddleName: | JOHN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | O.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1200 E ELDORADO PKWY | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | LITTLE ELM | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750685582 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9722920900 | ||||||||
| FaxNumber: | 9722920908 | ||||||||
| Practice Location | |||||||||
| Address1: | 1200 E ELDORADO PKWY | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | LITTLE ELM | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750685582 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9722920900 | ||||||||
| FaxNumber: | 9722920908 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/22/2005 | ||||||||
| LastUpdateDate: | 02/23/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 5893TG | TX | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 81008Q | 01 | TX | BLUECROSSBLUESHIELD | OTHER |