=====================================================
General NPI Number Information
=====================================================
NPI Number | 1487464855
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LASIK AND CATARACT SAN ANTONIO
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/08/2025
-----------------------------------------------------
Last Update Date | 01/08/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8002 WEST AVE
-----------------------------------------------------
City | SAN ANTONIO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78213-1865
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 210-348-8788
-----------------------------------------------------
Fax | 210-348-8768
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8002 WEST AVE
-----------------------------------------------------
City | SAN ANTONIO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78213-1865
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 210-348-8788
-----------------------------------------------------
Fax | 210-348-8768
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | RICARDO N SEPULVEDA
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 210-348-8788
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207W00000X
-----------------------------------------------------
Taxonomy Name | Ophthalmology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------