=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780947267
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | OLGA KOTLYAR, OD, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/20/2012
-----------------------------------------------------
Last Update Date | 06/20/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 103 YALE STREET SUITE 100 B
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77007
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 713-515-5626
-----------------------------------------------------
Fax | 281-890-9938
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10902 BRAES BAYOU DR
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77071-1809
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 713-515-5626
-----------------------------------------------------
Fax | 281-890-9938
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OPTOMETRIST
-----------------------------------------------------
Name | DR. OLGA KOTLYAR
-----------------------------------------------------
Credential | O.D.
-----------------------------------------------------
Telephone | 713-515-5626
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 6443TG
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------