Provider Demographics
NPI:1578553954
Name:SAN GABRIEL VALLEY EYE ASSOCIATES INC
Entity Type:Organization
Organization Name:SAN GABRIEL VALLEY EYE ASSOCIATES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:DEAN
Authorized Official - Last Name:RICHARDSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:626-289-7856
Mailing Address - Street 1:207 S SANTA ANITA AVE
Mailing Address - Street 2:SUITE P 25
Mailing Address - City:SAN GABRIEL
Mailing Address - State:CA
Mailing Address - Zip Code:91776-1138
Mailing Address - Country:US
Mailing Address - Phone:626-289-7856
Mailing Address - Fax:626-289-3328
Practice Address - Street 1:207 S SANTA ANITA AVE
Practice Address - Street 2:SUITE P 25
Practice Address - City:SAN GABRIEL
Practice Address - State:CA
Practice Address - Zip Code:91776-1138
Practice Address - Country:US
Practice Address - Phone:626-289-7856
Practice Address - Fax:626-289-3328
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
=========OtherBLUE CROSS BLUE SHIELD
W10696Medicare ID - Type Unspecified