Provider Demographics
NPI:1053403543
Name:EYE CLINIC OF AUSTIN PLLC THOMAS HENDERSON SOLE MBR
Entity type:Organization
Organization Name:EYE CLINIC OF AUSTIN PLLC THOMAS HENDERSON SOLE MBR
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:THOMAN
Authorized Official - Last Name:HENDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:512-427-1100
Mailing Address - Street 1:3410 FAR WEST BLVD
Mailing Address - Street 2:SUITE 140
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78731-3167
Mailing Address - Country:US
Mailing Address - Phone:512-427-1100
Mailing Address - Fax:512-427-1208
Practice Address - Street 1:3410 FAR WEST BLVD
Practice Address - Street 2:SUITE 140
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78731-3167
Practice Address - Country:US
Practice Address - Phone:512-427-1100
Practice Address - Fax:512-427-1207
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-29
Last Update Date:2012-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF4863207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX180008032OtherMEDICARE RAILROAD GRP
TX612710001OtherNATIONAL SUPPLIER CLEARIN
TX93945601Medicaid
TX115509501Medicaid
C16791Medicare UPIN
00N53JMedicare ID - Type UnspecifiedGRP
TX115509501Medicaid