1790736098 NPI number — RETINA CONSULTANTS SAN DIEGO INC

Table of content: (NPI 1790736098)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790736098 NPI number — RETINA CONSULTANTS SAN DIEGO INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RETINA CONSULTANTS SAN DIEGO 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 CONSULTANTS SAN DIEGO 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:
1790736098
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/06/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12630 MONTE VISTA RD
Provider Second Line Business Mailing Address:
SUITE 104
Provider Business Mailing Address City Name:
POWAY
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92064-2526
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
858-451-1911
Provider Business Mailing Address Fax Number:
858-451-0566

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12630 MONTE VISTA RD
Provider Second Line Business Practice Location Address:
SUITE 104
Provider Business Practice Location Address City Name:
POWAY
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92064-2526
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
858-451-1911
Provider Business Practice Location Address Fax Number:
858-451-0566
Provider Enumeration Date:
05/12/2006

Additional Information

Authorized Official

Authorized Official Last Name:
ING
Authorized Official First Name:
JOCELIN
Authorized Official Middle Name:
Authorized Official Title or Position:
PRACTICE ADMINISTRATOR
Authorized Official Telephone Number:
858-500-7815

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: DA1466 . This is a "MEDICARE RAILROAD" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: GR0045281 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: ZZZ30299Z . This is a "BLUE SHIELD" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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