Healthcare Provider Details

I. General information

NPI: 1982990925
Provider Name (Legal Business Name): HOUSTON RETINA CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/28/2011
Last Update Date: 06/28/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6012 CHARLOTTE ST
HOUSTON TX
77005-3120
US

IV. Provider business mailing address

6012 CHARLOTTE ST
HOUSTON TX
77005-3120
US

V. Phone/Fax

Practice location:
  • Phone: 318-623-1883
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberM3618
License Number StateTX

VIII. Authorized Official

Name: ANDREW KOPEL
Title or Position: PRESIDENT
Credential: M.D.
Phone: 318-623-1883