MEDICARE: HOUSTON RETINA CENTER

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	207W00000X	Ophthalmology Physician	M3618	TX

General Provider Information

NPI Number	:	1982990925
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HOUSTON RETINA CENTER

Provider Business Mailing Address
First Line	:	6012 CHARLOTTE ST
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77005-3120
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	6012 CHARLOTTE ST
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77005-3120
Country	:	US
Telephone Number	:	318-623-1883
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	ANDREW KOPEL
Credential	:	M.D.
Telephone Number	:	318-623-1883

Provider Enumeration Date	:	06/28/2011
Last Update Date	:	06/28/2011

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