Provider Demographics
NPI:1578643615
Name:RETINA EYE SPECIALISTS PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:RETINA EYE SPECIALISTS PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RAGHU
Authorized Official - Middle Name:C
Authorized Official - Last Name:MURTHY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:626-202-2446
Mailing Address - Street 1:1936 HUNTINGTON DR
Mailing Address - Street 2:SUITE A
Mailing Address - City:SOUTH PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91030-4859
Mailing Address - Country:US
Mailing Address - Phone:626-202-2446
Mailing Address - Fax:626-795-0121
Practice Address - Street 1:1936 HUNTINGTON DR
Practice Address - Street 2:SUITE A
Practice Address - City:SOUTH PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91030-4859
Practice Address - Country:US
Practice Address - Phone:626-202-2446
Practice Address - Fax:626-795-0121
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-16
Last Update Date:2014-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA66228207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW18125Medicare ID - Type Unspecified