1083707822 NPI number — VITREO-RETINAL MEDICAL GROUP, INC.

Table of content: (NPI 1083707822)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083707822 NPI number — VITREO-RETINAL MEDICAL GROUP, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
VITREO-RETINAL MEDICAL GROUP, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
RETINA CENTER OF STOCKTON, INC.
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1083707822
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/06/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3 PARK CENTER DR STE 100
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SACRAMENTO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95825-8340
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
916-514-5469
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3555 DEER PARK DR
Provider Second Line Business Practice Location Address:
SUITE 180
Provider Business Practice Location Address City Name:
STOCKTON
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95219-2377
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
209-938-0496
Provider Business Practice Location Address Fax Number:
209-951-5231
Provider Enumeration Date:
10/02/2006

Additional Information

Authorized Official

Authorized Official Last Name:
PEARLMAN
Authorized Official First Name:
JOEL
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
916-596-2027

Provider Taxonomy Codes

  • Taxonomy code: 207W00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: ZZZ14095Z . This is a "BLUE SHIELD CA" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 0199873 . This is a "DEPT OF LABOR WA" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: GR0030322 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: ZZZ14095Z . This is a "WORKERS COMP." identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: CP5300 . This is a "RAILROAD MEDI-CARE" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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