Provider Demographics
NPI:1528089398
Name:BEVERLY ANN KOTARA WIATREK, OD
Entity type:Organization
Organization Name:BEVERLY ANN KOTARA WIATREK, OD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BEVERLY
Authorized Official - Middle Name:
Authorized Official - Last Name:WIATREK
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:210-534-8863
Mailing Address - Street 1:3310 E SOUTHCROSS BLVD
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78223-1922
Mailing Address - Country:US
Mailing Address - Phone:210-534-8863
Mailing Address - Fax:210-534-8551
Practice Address - Street 1:3310 E SOUTHCROSS BLVD
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78223-1922
Practice Address - Country:US
Practice Address - Phone:210-534-8863
Practice Address - Fax:210-534-8551
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00E47EMedicare ID - Type Unspecified
TXT16611Medicare UPIN