Provider Demographics
NPI:1275631434
Name:LOS ANGELES INSTITUTE FOR OPHTHALMIC SURGERY
Entity Type:Organization
Organization Name:LOS ANGELES INSTITUTE FOR OPHTHALMIC SURGERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:COLVARD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-906-2929
Mailing Address - Street 1:5363 BALBOA BLVD
Mailing Address - Street 2:SUITE 545
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91316-2805
Mailing Address - Country:US
Mailing Address - Phone:818-906-2929
Mailing Address - Fax:818-906-0567
Practice Address - Street 1:5363 BALBOA BLVD
Practice Address - Street 2:SUITE 545
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91316-2805
Practice Address - Country:US
Practice Address - Phone:818-906-2929
Practice Address - Fax:818-906-0567
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2010-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG39377207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0071330Medicaid
CAA47802Medicare UPIN
CAGR0071330Medicaid