Provider Demographics
NPI:1518020841
Name:MHR EYE ASSOCIATION, P.A.
Entity type:Organization
Organization Name:MHR EYE ASSOCIATION, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:DEANNA
Authorized Official - Middle Name:
Authorized Official - Last Name:TIDWELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-310-6080
Mailing Address - Street 1:1310 N WHITE CHAPEL BLVD STE 208
Mailing Address - Street 2:
Mailing Address - City:SOUTHLAKE
Mailing Address - State:TX
Mailing Address - Zip Code:76092-4308
Mailing Address - Country:US
Mailing Address - Phone:817-310-6080
Mailing Address - Fax:817-310-6014
Practice Address - Street 1:1310 N WHITE CHAPEL BLVD STE 208
Practice Address - Street 2:
Practice Address - City:SOUTHLAKE
Practice Address - State:TX
Practice Address - Zip Code:76092-4308
Practice Address - Country:US
Practice Address - Phone:817-310-6080
Practice Address - Fax:817-310-6014
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-18
Last Update Date:2023-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0007NCOtherBLUECROSSBLUESHIELD
TX5158536OtherAETNA
TX00600YMedicare PIN
TX00944ZMedicare PIN