Provider Demographics
NPI:1467558361
Name:PACIFIC CHILDRENS EYECARE MEDICAL GROUP
Entity Type:Organization
Organization Name:PACIFIC CHILDRENS EYECARE MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWENER
Authorized Official - Prefix:
Authorized Official - First Name:THEODORE
Authorized Official - Middle Name:OTIS
Authorized Official - Last Name:PAUL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:925-363-8170
Mailing Address - Street 1:5528 PACHECO BLVD
Mailing Address - Street 2:BUILDING A
Mailing Address - City:PACHECO
Mailing Address - State:CA
Mailing Address - Zip Code:94553-5126
Mailing Address - Country:US
Mailing Address - Phone:925-363-8170
Mailing Address - Fax:925-363-4995
Practice Address - Street 1:1517 NORTH POINT ST.
Practice Address - Street 2:#471
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94123
Practice Address - Country:US
Practice Address - Phone:415-923-3926
Practice Address - Fax:415-276-3783
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-16
Last Update Date:2007-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA22914207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAF19858Medicare UPIN