Provider Demographics
NPI:1275619751
Name:BRYANT J. LUM MD
Entity Type:Organization
Organization Name:BRYANT J. LUM MD
Other - Org Name:VENTURA OPHTHALMOLOGY MEDICAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:
Authorized Official - Last Name:WINTERMUTE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:805-648-6891
Mailing Address - Street 1:3088 TELEGRAPH RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:VENTURA
Mailing Address - State:CA
Mailing Address - Zip Code:93003-3234
Mailing Address - Country:US
Mailing Address - Phone:805-648-6891
Mailing Address - Fax:805-648-6386
Practice Address - Street 1:3088 TELEGRAPH RD
Practice Address - Street 2:SUITE A
Practice Address - City:VENTURA
Practice Address - State:CA
Practice Address - Zip Code:93003-3234
Practice Address - Country:US
Practice Address - Phone:805-648-6891
Practice Address - Fax:805-648-6386
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-27
Last Update Date:2010-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA45040207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAE23351Medicare UPIN
CA0576520001Medicare NSC
CAW12217Medicare PIN