Provider Demographics
NPI:1568893659
Name:CAPITAL EYE MEDICAL GROUP
Entity Type:Organization
Organization Name:CAPITAL EYE MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MITRA
Authorized Official - Middle Name:
Authorized Official - Last Name:AYAZIFAR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:916-960-9176
Mailing Address - Street 1:PO BOX 279
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95660-0279
Mailing Address - Country:US
Mailing Address - Phone:916-960-9176
Mailing Address - Fax:
Practice Address - Street 1:817 COURT ST STE 10
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:CA
Practice Address - Zip Code:95642-2156
Practice Address - Country:US
Practice Address - Phone:209-223-2020
Practice Address - Fax:209-223-2046
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-27
Last Update Date:2019-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty