MEDICARE: BAYSHORE OPTICAL COMPANY

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

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0041DG	OTHER	TX	BLUE CROSS BLUE SHIELD
2	0991490001	OTHER		PALMETTO

General Provider Information

NPI Number	:	1689785560
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BAYSHORE OPTICAL COMPANY

Provider Business Mailing Address
First Line	:	3320 PLAINVIEW ST
Second Line	:
City	:	PASADENA
State	:	TX
Zip	:	77504-1906
Country	:	US
Telephone Number	:	713-944-4828
Fax Number	:	713-944-1401

Provider Business Practice Location Address
First Line	:	3320 PLAINVIEW ST
Second Line	:
City	:	PASADENA
State	:	TX
Zip	:	77504-1906
Country	:	US
Telephone Number	:	713-944-4828
Fax Number	:	713-944-1401

Authorized Official
Title or Position	:	M.D.
Name	:	PETER M. HOLLAND
Credential	:	M.D.
Telephone Number	:	713-944-4828

Provider Enumeration Date	:	08/31/2006
Last Update Date	:	08/22/2020

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Directions to “BAYSHORE OPTICAL COMPANY ” Practice Location

Language	Start Address	Practice Location

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