MEDICARE: BERKELEY EYE INSTITUTE, PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	152W00000X	Optometrist
2	332H00000X	Eyewear Supplier
3	207W00000X	Ophthalmology Physician

General Provider Information

NPI Number	:	1346082872
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BERKELEY EYE INSTITUTE, PLLC

Provider Business Mailing Address
First Line	:	306 N MAIN ST STE A
Second Line	:
City	:	DAYTON
State	:	TX
Zip	:	77535-2635
Country	:	US
Telephone Number	:	936-258-0020
Fax Number	:	936-257-8111

Provider Business Practice Location Address
First Line	:	306 N MAIN ST STE A
Second Line	:
City	:	DAYTON
State	:	TX
Zip	:	77535-2635
Country	:	US
Telephone Number	:	936-258-0020
Fax Number	:	936-257-8111

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	MARK MICHELETTI
Credential	:
Telephone Number	:	281-348-4615

Provider Enumeration Date	:	06/06/2024
Last Update Date	:	10/04/2024

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