Provider Demographics
NPI:1316199110
Name:DOHENY EYE MEDICAL GROUP, INC
Entity Type:Organization
Organization Name:DOHENY EYE MEDICAL GROUP, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:
Authorized Official - First Name:RONAL
Authorized Official - Middle Name:E
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:323-442-7124
Mailing Address - Street 1:1450 SAN PABLO ST
Mailing Address - Street 2:SUITE 3700
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90033-4500
Mailing Address - Country:US
Mailing Address - Phone:323-442-7124
Mailing Address - Fax:
Practice Address - Street 1:7777 MILLIKEN AVE
Practice Address - Street 2:SUITE 125
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-6780
Practice Address - Country:US
Practice Address - Phone:323-442-7160
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DOHENY EYE MEDICAL GROUP, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-10-13
Last Update Date:2008-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center