Healthcare Provider Details

I. General information

NPI: 1700334794
Provider Name (Legal Business Name): EYE DOCTORS OF SOUTH TEXAS, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/19/2016
Last Update Date: 12/29/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

427 N LOOP 1604 W SUITE 203
SAN ANTONIO TX
78232-1033
US

IV. Provider business mailing address

427 N LOOP 1604 W STE 203
SAN ANTONIO TX
78232-1033
US

V. Phone/Fax

Practice location:
  • Phone: 210-960-5494
  • Fax: 210-960-2261
Mailing address:
  • Phone: 210-960-5494
  • Fax: 210-960-2261

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number8129TG
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code152WL0500X
TaxonomyLow Vision Rehabilitation Optometrist
License Number8129TG
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code152WP0200X
TaxonomyPediatric Optometrist
License Number8129TG
License Number StateTX
# 4
Primary TaxonomyN
Taxonomy Code152WS0006X
TaxonomySports Vision Optometrist
License Number8129TG
License Number StateTX
# 5
Primary TaxonomyN
Taxonomy Code152WV0400X
TaxonomyVision Therapy Optometrist
License Number8129TG
License Number StateTX
# 6
Primary TaxonomyN
Taxonomy Code152WX0102X
TaxonomyOccupational Vision Optometrist
License Number8129TG
License Number StateTX
# 7
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number8129TG
License Number StateTX

VIII. Authorized Official

Name: DR. TONI WYNN RACOMA
Title or Position: MANAGING MEMBER
Credential: O.D.
Phone: 609-312-1115