Provider Demographics
NPI:1629196118
Name:RETINA INSTITUTE OF SOUTH TEXAS
Entity type:Organization
Organization Name:RETINA INSTITUTE OF SOUTH TEXAS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WENDALL
Authorized Official - Middle Name:
Authorized Official - Last Name:BAUMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:210-654-0400
Mailing Address - Street 1:137 PRIMROSE PL
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78209-3832
Mailing Address - Country:US
Mailing Address - Phone:210-654-0400
Mailing Address - Fax:210-654-0460
Practice Address - Street 1:11651 TOEPPERWEIN RD
Practice Address - Street 2:STE 201
Practice Address - City:LIVE OAK
Practice Address - State:TX
Practice Address - Zip Code:78233-3147
Practice Address - Country:US
Practice Address - Phone:210-654-0400
Practice Address - Fax:210-654-0460
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-26
Last Update Date:2014-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ4706174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX175842701Medicaid
TX034567003Medicaid
TX00306ZMedicare ID - Type UnspecifiedGROUP
TX175842701Medicaid
TX8F0845Medicare ID - Type UnspecifiedGROUP INDIVIDUAL