Provider Demographics
NPI:1518030568
Name:RETINAL DIAGNOSTIC CENTER A MEDICAL CORPORATION
Entity Type:Organization
Organization Name:RETINAL DIAGNOSTIC CENTER A MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TIM
Authorized Official - Middle Name:
Authorized Official - Last Name:KELLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:408-559-0666
Mailing Address - Street 1:3395 S. BASCOM AVE.
Mailing Address - Street 2:SUITE 140
Mailing Address - City:CAMPBELL
Mailing Address - State:CA
Mailing Address - Zip Code:95008
Mailing Address - Country:US
Mailing Address - Phone:408-559-0666
Mailing Address - Fax:408-963-5920
Practice Address - Street 1:3395 S. BASCOM AVE.
Practice Address - Street 2:SUITE 140
Practice Address - City:CAMPBELL
Practice Address - State:CA
Practice Address - Zip Code:95008
Practice Address - Country:US
Practice Address - Phone:408-559-0666
Practice Address - Fax:408-963-5920
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-16
Last Update Date:2023-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC37086174400000X
CAG60723174400000X
CAG83824174400000X
CAA53889174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G838240Medicaid
CA00G607230Medicaid
CA00C370860Medicaid
CA00A538890Medicaid
CA00A538890Medicaid
CA00G607230Medicare ID - Type Unspecified
CA00G607230Medicaid
CAG12110Medicare UPIN
CAG52850Medicare UPIN
CA00G838240Medicaid
CA00G838240Medicare ID - Type Unspecified
CA00C370860Medicaid