Provider Demographics
NPI:1568030260
Name:EYE SPECIALTIES MEDICAL GROUP INC.
Entity Type:Organization
Organization Name:EYE SPECIALTIES MEDICAL GROUP INC.
Other - Org Name:EYE SPECIALTIES MEDICAL GROUP INC.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:DEBORAH
Authorized Official - Middle Name:H
Authorized Official - Last Name:TAFOYA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:510-881-8823
Mailing Address - Street 1:20046 LAKE CHABOT RD
Mailing Address - Street 2:
Mailing Address - City:CASTRO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:94546-5304
Mailing Address - Country:US
Mailing Address - Phone:510-881-8823
Mailing Address - Fax:510-881-2134
Practice Address - Street 1:20046 LAKE CHABOT RD
Practice Address - Street 2:
Practice Address - City:CASTRO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:94546-5304
Practice Address - Country:US
Practice Address - Phone:510-881-8823
Practice Address - Fax:510-881-2134
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-06-17
Last Update Date:2021-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1007110001Medicaid