Provider Demographics
NPI:1336318807
Name:GREGORY B. MCMAHILL, OD, AN OPTOMETRIC CORPORATION
Entity Type:Organization
Organization Name:GREGORY B. MCMAHILL, OD, AN OPTOMETRIC CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:BRIAN
Authorized Official - Last Name:MCMAHILL
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:760-202-0100
Mailing Address - Street 1:72800 DINAH SHORE DR
Mailing Address - Street 2:
Mailing Address - City:PALM DESERT
Mailing Address - State:CA
Mailing Address - Zip Code:92211-0814
Mailing Address - Country:US
Mailing Address - Phone:760-202-0100
Mailing Address - Fax:760-202-0121
Practice Address - Street 1:72800 DINAH SHORE DR
Practice Address - Street 2:
Practice Address - City:PALM DESERT
Practice Address - State:CA
Practice Address - Zip Code:92211-0814
Practice Address - Country:US
Practice Address - Phone:760-202-0100
Practice Address - Fax:760-202-0121
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-28
Last Update Date:2011-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT9489TPA152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAU13914Medicare UPIN
CABB778BMedicare PIN