MEDICARE: ADVANCED EYECARE ASSOCIATES PC

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	152WC0802X	Corneal and Contact Management Optometrist	4584TG	TX
2	152WP0200X	Pediatric Optometrist	4584TG	TX
3	152WS0006X	Sports Vision Optometrist	4584TG	TX
4	152W00000X	Optometrist	4584TG	TX

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0A3610	OTHER	TX	MEDICARE PTAN GROUP

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	2061598	OTHER	TX	FIRST HEALTH GROUP #
3	95266	OTHER	TX	HARRINGTON GROUP #
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1487870309
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ADVANCED EYECARE ASSOCIATES PC

Provider Business Mailing Address
First Line	:	18170 DALLAS PKWY
Second Line	:	SUITE 402
City	:	DALLAS
State	:	TX
Zip	:	75287-7137
Country	:	US
Telephone Number	:	972-931-2020
Fax Number	:	972-407-9452

Provider Business Practice Location Address
First Line	:	18170 DALLAS PKWY
Second Line	:	SUITE 402
City	:	DALLAS
State	:	TX
Zip	:	75287-7137
Country	:	US
Telephone Number	:	972-931-2020
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. DONALD D DERRYBERRY JR.
Credential	:	O.D.
Telephone Number	:	972-931-2020

Provider Enumeration Date	:	04/18/2007
Last Update Date	:	04/20/2009

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