MEDICARE: ANGELO EYE ASSOCIATES PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	05712TG	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	1114028883	OTHER	TX	INDIVIDUAL NPI
3	80301Q	OTHER	TX	BCBS

General Provider Information

NPI Number	:	1366591539
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ANGELO EYE ASSOCIATES PA

Provider Business Mailing Address
First Line	:	1721 KNICKERBOCKER RD
Second Line	:
City	:	SAN ANGELO
State	:	TX
Zip	:	76904-5521
Country	:	US
Telephone Number	:	325-944-8531
Fax Number	:	325-944-4213

Provider Business Practice Location Address
First Line	:	1721 KNICKERBOCKER RD
Second Line	:
City	:	SAN ANGELO
State	:	TX
Zip	:	76904-5521
Country	:	US
Telephone Number	:	325-944-8531
Fax Number	:	325-944-4213

Authorized Official
Title or Position	:	ASSISTANT
Name	:	MRS. LACI RAY
Credential	:
Telephone Number	:	325-944-8531

Provider Enumeration Date	:	01/09/2007
Last Update Date	:	10/11/2016

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Directions to “ANGELO EYE ASSOCIATES PA ” Practice Location

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