Provider Demographics
NPI:1265661821
Name:CENTER FOR RETINAL AND MACULAR DISEASES, INC.
Entity Type:Organization
Organization Name:CENTER FOR RETINAL AND MACULAR DISEASES, INC.
Other - Org Name:CENTER FOR RETINAL AND MACULAR DISEASES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:LEONID
Authorized Official - Middle Name:E
Authorized Official - Last Name:LERNER
Authorized Official - Suffix:
Authorized Official - Credentials:MD, PHD
Authorized Official - Phone:949-500-3207
Mailing Address - Street 1:1441 AVOCADO AVE
Mailing Address - Street 2:SUITE 204
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92660-7721
Mailing Address - Country:US
Mailing Address - Phone:949-500-3207
Mailing Address - Fax:949-612-1910
Practice Address - Street 1:1440 AVOCADO AVENUE
Practice Address - Street 2:SUITE 204
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660
Practice Address - Country:US
Practice Address - Phone:949-721-1701
Practice Address - Fax:949-612-1910
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-04
Last Update Date:2015-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA54458207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACT593AOtherMEDICARE PTAN
CACT593BOtherMEDICARE PTAN