Provider Demographics
NPI:1083813380
Name:EYE CARE FOR DIABETICS MEDICAL GROUP, INC
Entity Type:Organization
Organization Name:EYE CARE FOR DIABETICS MEDICAL GROUP, INC
Other - Org Name:EYE CARE FOR DIABETICS MEDICAL GROUP, INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OPHTHALMOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:LEROY
Authorized Official - Middle Name:W
Authorized Official - Last Name:VAUGHN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-671-0909
Mailing Address - Street 1:323 N PRAIRIE AVE
Mailing Address - Street 2:217
Mailing Address - City:INGLEWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90301-4502
Mailing Address - Country:US
Mailing Address - Phone:310-671-0909
Mailing Address - Fax:310-412-0066
Practice Address - Street 1:323 N PRAIRIE AVE
Practice Address - Street 2:217
Practice Address - City:INGLEWOOD
Practice Address - State:CA
Practice Address - Zip Code:90301-4502
Practice Address - Country:US
Practice Address - Phone:310-671-0909
Practice Address - Fax:310-412-0066
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-16
Last Update Date:2021-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA00305761Medicaid
CAA00305761Medicaid
CAW14178Medicare PIN