Provider Demographics
NPI:1306853452
Name:EYE MEDICAL CLINIC OF FRESNO, INC
Entity Type:Organization
Organization Name:EYE MEDICAL CLINIC OF FRESNO, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:A
Authorized Official - Last Name:BERTOLUCCI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:559-449-5097
Mailing Address - Street 1:1360 E HERNDON AVE
Mailing Address - Street 2:SUITE 301
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93720-3326
Mailing Address - Country:US
Mailing Address - Phone:559-486-5000
Mailing Address - Fax:559-439-7854
Practice Address - Street 1:1360 E HERNDON AVE
Practice Address - Street 2:SUITE 301
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93720-3326
Practice Address - Country:US
Practice Address - Phone:559-486-5000
Practice Address - Fax:559-439-7854
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-02
Last Update Date:2009-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGSD005250Medicaid
CAZZZ17909ZMedicaid
CAGSD005250Medicaid
CA0395590001Medicare NSC
CACI3011Medicare PIN