Healthcare Provider Details

I. General information

NPI: 1407826415
Provider Name (Legal Business Name): WATERLOO EYE ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/23/2006
Last Update Date: 12/12/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12171 W PARMER LN SUITE 201
CEDAR PARK TX
78613-7361
US

IV. Provider business mailing address

12171 W PARMER LN SUITE 201
CEDAR PARK TX
78613-7361
US

V. Phone/Fax

Practice location:
  • Phone: 512-528-1144
  • Fax: 512-528-1143
Mailing address:
  • Phone: 512-528-1144
  • Fax: 512-528-1143

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. VINCENT ANTHONY RESTIVO
Title or Position: PRESIDENT
Credential: MD
Phone: 512-528-1144