Provider Demographics
NPI:1043539885
Name:PEDIATRIC EYE CARE & SURGERY MEDICAL CORPORATION
Entity Type:Organization
Organization Name:PEDIATRIC EYE CARE & SURGERY MEDICAL CORPORATION
Other - Org Name:PEDIATRIC EYE CARE & SURGERY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SARAH
Authorized Official - Middle Name:JENNIFER
Authorized Official - Last Name:WHANG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:714-633-0321
Mailing Address - Street 1:302 W LA VETA AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92866-2607
Mailing Address - Country:US
Mailing Address - Phone:714-633-0321
Mailing Address - Fax:714-633-9196
Practice Address - Street 1:302 W LA VETA AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92866-2607
Practice Address - Country:US
Practice Address - Phone:714-633-0321
Practice Address - Fax:714-633-9196
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-18
Last Update Date:2010-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC54031207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAC54031OtherLICENSE