Provider Demographics
NPI:1659406445
Name:PLAZA EYE & SURGERY CENTER, A MEDICAL CORPORATION
Entity Type:Organization
Organization Name:PLAZA EYE & SURGERY CENTER, A MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPHTHALMOLOGIST AND OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:A
Authorized Official - Last Name:BERNSTEIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:213-749-5555
Mailing Address - Street 1:1414 S GRAND AVE
Mailing Address - Street 2:#100
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90015-3067
Mailing Address - Country:US
Mailing Address - Phone:213-749-5555
Mailing Address - Fax:213-749-5253
Practice Address - Street 1:1414 S GRAND AVE
Practice Address - Street 2:#100
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90015-3067
Practice Address - Country:US
Practice Address - Phone:213-749-5555
Practice Address - Fax:213-749-5253
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-22
Last Update Date:2010-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNC30903152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact ManagementGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0090870Medicaid
CAGR0090870Medicaid
CAA34401Medicare UPIN
CAW15376Medicare PIN