1790965341 NPI number — EAST BAY RETINA CONSULTANTS A MEDICAL GROUP, INC.

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 1790965341 NPI number — EAST BAY RETINA CONSULTANTS A MEDICAL GROUP, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EAST BAY RETINA CONSULTANTS A 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:
Provider Other Organization Name Type Code:
6
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:
1790965341
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/13/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3300 TELEGRAPH AVE.
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OAKLAND
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
94609-3028
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
510-444-1600
Provider Business Mailing Address Fax Number:
510-444-5117

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3300 TELEGRAPH AVE.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OAKLAND
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94609-3028
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
510-444-1600
Provider Business Practice Location Address Fax Number:
510-444-5117
Provider Enumeration Date:
11/13/2007

Additional Information

Authorized Official

Authorized Official Last Name:
LEE
Authorized Official First Name:
SOON
Authorized Official Middle Name:
T.
Authorized Official Title or Position:
CORPORATE VICE PRESIDENT
Authorized Official Telephone Number:
510-444-1600

Provider Taxonomy Codes

  • Taxonomy code: 207W00000X , with the licence number:  G57682 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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