Provider Demographics
NPI:1386669265
Name:RETINA ASSOCIATES MEDICAL GROUP INC
Entity Type:Organization
Organization Name:RETINA ASSOCIATES MEDICAL GROUP INC
Other - Org Name:THE RETINA INSTITUTE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:F
Authorized Official - Last Name:RUPER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:714-633-6060
Mailing Address - Street 1:436 S GLASSELL ST
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92866-1906
Mailing Address - Country:US
Mailing Address - Phone:714-633-6060
Mailing Address - Fax:714-633-7470
Practice Address - Street 1:436 S GLASSELL ST
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92866-1906
Practice Address - Country:US
Practice Address - Phone:714-633-6060
Practice Address - Fax:714-633-7470
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-13
Last Update Date:2010-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00C300760Medicaid
CADG3183Medicare PIN
CA00C300760Medicaid