1699392506 NPI number — DESERT OPHTHALMOLOGY MEDICAL CORPORATION

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1699392506 NPI number — DESERT OPHTHALMOLOGY MEDICAL CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DESERT OPHTHALMOLOGY MEDICAL CORPORATION
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:
Provider Other Organization Name Type Code:
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:
1699392506
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/26/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
72650 FRED WARING DR STE 109
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PALM DESERT
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92260-5008
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
760-776-8600
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
72650 FRED WARING DR STE 109
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PALM DESERT
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92260-5008
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-776-8600
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/26/2020

Additional Information

Authorized Official

Authorized Official Last Name:
GOLDBAN
Authorized Official First Name:
WALLACE
Authorized Official Middle Name:
FRANKLIN
Authorized Official Title or Position:
PRACTICE OWNER
Authorized Official Telephone Number:
760-320-8497

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)





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