Provider Demographics
NPI:1447215975
Name:ENVISION EYE, A PROFESSIONAL MEDICAL CORPORATION
Entity Type:Organization
Organization Name:ENVISION EYE, A PROFESSIONAL MEDICAL CORPORATION
Other - Org Name:ASSOCIATED EYE SURGEONS MEDICAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PADMA
Authorized Official - Middle Name:
Authorized Official - Last Name:NANDURI
Authorized Official - Suffix:
Authorized Official - Credentials:MD, FACS
Authorized Official - Phone:858-450-1010
Mailing Address - Street 1:9834 GENESEE AVE
Mailing Address - Street 2:SUITE 406
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92037-1223
Mailing Address - Country:US
Mailing Address - Phone:858-450-1010
Mailing Address - Fax:858-450-9451
Practice Address - Street 1:9834 GENESEE AVE
Practice Address - Street 2:SUITE 406
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92037-1223
Practice Address - Country:US
Practice Address - Phone:858-450-1010
Practice Address - Fax:858-450-9451
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-18
Last Update Date:2008-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA4437280001Medicare NSC