Provider Demographics
NPI:1043473390
Name:LAKEWOOD EYE PHYSICIANS AND SURGEONS INC A MEDICAL GROUP
Entity Type:Organization
Organization Name:LAKEWOOD EYE PHYSICIANS AND SURGEONS INC A MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING
Authorized Official - Prefix:MRS
Authorized Official - First Name:CAROLINE
Authorized Official - Middle Name:
Authorized Official - Last Name:BARRAGAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:562-531-2020
Mailing Address - Street 1:3300 E SOUTH ST
Mailing Address - Street 2:SUITE 105
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90805-4550
Mailing Address - Country:US
Mailing Address - Phone:562-531-2020
Mailing Address - Fax:562-531-1142
Practice Address - Street 1:3300 E SOUTH ST
Practice Address - Street 2:SUITE 107
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90805-4550
Practice Address - Country:US
Practice Address - Phone:562-531-2020
Practice Address - Fax:562-531-1142
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-08
Last Update Date:2009-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ79385ZMedicaid
CAZZZ79385ZMedicaid