Healthcare Provider Details

I. General information

NPI: 1225319247
Provider Name (Legal Business Name): PRESTIGE VISION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/03/2011
Last Update Date: 09/03/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2317 SOUTHBAY CIR
ROWLETT TX
75088-5531
US

IV. Provider business mailing address

601 S PLANO RD
RICHARDSON TX
75081-4512
US

V. Phone/Fax

Practice location:
  • Phone: 214-728-6716
  • Fax:
Mailing address:
  • Phone: 214-613-5204
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number7707T
License Number StateTX

VIII. Authorized Official

Name: MS. ROXY MARKOSE
Title or Position: OWNER
Credential: O.D.
Phone: 214-728-6716