Provider Demographics
NPI:1235168055
Name:SAN PEDRO EYE MEDICAL GROUP, INC A PROFESSIONAL MEDICAL CORPORATION
Entity Type:Organization
Organization Name:SAN PEDRO EYE MEDICAL GROUP, INC A PROFESSIONAL MEDICAL CORPORATION
Other - Org Name:SAN PEDRO EYE CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GENE
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:CALKINS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:310-833-1327
Mailing Address - Street 1:571 W 7TH ST
Mailing Address - Street 2:
Mailing Address - City:SAN PEDRO
Mailing Address - State:CA
Mailing Address - Zip Code:90731-3115
Mailing Address - Country:US
Mailing Address - Phone:310-833-1327
Mailing Address - Fax:310-833-0698
Practice Address - Street 1:571 W 7TH ST
Practice Address - Street 2:
Practice Address - City:SAN PEDRO
Practice Address - State:CA
Practice Address - Zip Code:90731-3115
Practice Address - Country:US
Practice Address - Phone:310-833-1327
Practice Address - Fax:310-833-0698
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-02
Last Update Date:2018-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA4919152W00000X
CA7967152W00000X
CAG14368174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
No174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA6153850001Medicare NSC
CAA39241Medicare UPIN
CAT69966Medicare UPIN
CAU27766Medicare UPIN