Provider Demographics
NPI:1396840633
Name:CROWN CITY EYE CENTER MEDICAL GROUP
Entity Type:Organization
Organization Name:CROWN CITY EYE CENTER MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:G
Authorized Official - Last Name:ULRICH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:619-435-3955
Mailing Address - Street 1:1317 YNEZ PL
Mailing Address - Street 2:SUITE A
Mailing Address - City:CORONADO
Mailing Address - State:CA
Mailing Address - Zip Code:92118-3912
Mailing Address - Country:US
Mailing Address - Phone:619-435-3955
Mailing Address - Fax:619-435-9197
Practice Address - Street 1:1317 YNEZ PL
Practice Address - Street 2:SUITE A
Practice Address - City:CORONADO
Practice Address - State:CA
Practice Address - Zip Code:92118-3912
Practice Address - Country:US
Practice Address - Phone:619-435-3955
Practice Address - Fax:619-435-9197
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA=========OtherTAX ID