Provider Demographics
NPI:1639119050
Name:OPHTHALMIC FACIAL PLASTIC SURGERY INSTITUTE A MEDICAL CORPORATION
Entity Type:Organization
Organization Name:OPHTHALMIC FACIAL PLASTIC SURGERY INSTITUTE A MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SAM
Authorized Official - Middle Name:
Authorized Official - Last Name:GOLDBERGER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:714-449-1940
Mailing Address - Street 1:9735 WILSHIRE BLVD.
Mailing Address - Street 2:STE 319
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:90212-2100
Mailing Address - Country:US
Mailing Address - Phone:310-276-0044
Mailing Address - Fax:310-271-7003
Practice Address - Street 1:301 W BASTANCHURY RD
Practice Address - Street 2:SUITE 191
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92835-3419
Practice Address - Country:US
Practice Address - Phone:714-449-1940
Practice Address - Fax:714-449-1988
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:OPHTHALMIC FACIAL PLASTIC SURGERY INSTITUTE A MEDICAL CORPORATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-06-07
Last Update Date:2013-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAWG62027I174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWG62027IMedicare ID - Type UnspecifiedPROVIDER ID
CAW18547Medicare ID - Type UnspecifiedGROUP ID