Provider Demographics
NPI:1619926755
Name:EYE SURGERY CTR OF SO CALIF A MED GROUP
Entity Type:Organization
Organization Name:EYE SURGERY CTR OF SO CALIF A MED GROUP
Other - Org Name:TRI-CITY SURGERY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ANUJ
Authorized Official - Middle Name:
Authorized Official - Last Name:GUPTA
Authorized Official - Suffix:
Authorized Official - Credentials:MD,
Authorized Official - Phone:619-330-8771
Mailing Address - Street 1:2023 W VISTA WAY
Mailing Address - Street 2:SUITE E
Mailing Address - City:VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:92083-6030
Mailing Address - Country:US
Mailing Address - Phone:760-941-8152
Mailing Address - Fax:760-941-8967
Practice Address - Street 1:2023 W VISTA WAY
Practice Address - Street 2:STE E
Practice Address - City:VISTA
Practice Address - State:CA
Practice Address - Zip Code:92083-6030
Practice Address - Country:US
Practice Address - Phone:760-941-8152
Practice Address - Fax:760-941-8967
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-08
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA261QA1903X
CA080000475261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASUR01020FMedicaid
CASUR01020FMedicaid