Healthcare Provider Details

I. General information

NPI: 1225037955
Provider Name (Legal Business Name): DEHAVEN EYE CLINIC PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/15/2005
Last Update Date: 09/18/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1424 E FRONT ST
TYLER TX
75702-8501
US

IV. Provider business mailing address

PO BOX 130639
TYLER TX
75713-0639
US

V. Phone/Fax

Practice location:
  • Phone: 903-595-4144
  • Fax: 903-526-5491
Mailing address:
  • Phone: 903-595-7508
  • Fax: 903-526-5491

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number
License Number State

VIII. Authorized Official

Name: MRS. GINA LOWNDES
Title or Position: FINANCIAL SERVICE MANAGER
Credential:
Phone: 903-595-7510