Provider Demographics
NPI:1609975366
Name:CENTRAL VALLEY EYE MEDICAL GROUP INC.
Entity Type:Organization
Organization Name:CENTRAL VALLEY EYE MEDICAL GROUP INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:STEVENS
Authorized Official - Middle Name:Y
Authorized Official - Last Name:KIM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:209-952-3700
Mailing Address - Street 1:36 WEST YOKUTS AVE
Mailing Address - Street 2:SUITE 1
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95207-5713
Mailing Address - Country:US
Mailing Address - Phone:209-952-3700
Mailing Address - Fax:209-478-3302
Practice Address - Street 1:36 WEST YOKUTS AVE
Practice Address - Street 2:SUITE 1
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95207-5713
Practice Address - Country:US
Practice Address - Phone:209-952-3700
Practice Address - Fax:209-478-3302
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-21
Last Update Date:2013-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA152W00000X, 207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
No152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0076150Medicaid
CAZZZ05923ZMedicare PIN
CAGR0076150Medicaid