Provider Demographics
NPI:1104219286
Name:RETINA INSTITUTE OF CALIFORNIA MEDICAL GROUP
Entity Type:Organization
Organization Name:RETINA INSTITUTE OF CALIFORNIA MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FOUNDER
Authorized Official - Prefix:DR
Authorized Official - First Name:TOM
Authorized Official - Middle Name:S
Authorized Official - Last Name:CHANG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:626-568-8838
Mailing Address - Street 1:100 E CALIFORNIA BLVD
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91105-3205
Mailing Address - Country:US
Mailing Address - Phone:626-568-8838
Mailing Address - Fax:626-574-7188
Practice Address - Street 1:44139 MONTEREY AVE
Practice Address - Street 2:SUITE A
Practice Address - City:PALM DESERT
Practice Address - State:CA
Practice Address - Zip Code:92260-8700
Practice Address - Country:US
Practice Address - Phone:760-779-0800
Practice Address - Fax:760-779-0801
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-12
Last Update Date:2015-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA69909152W00000X, 174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
No152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1760541569OtherGROUP NPI
CA1760541569OtherGROUP NPI
CABW463AMedicare UPIN