Provider Demographics
NPI:1679855076
Name:EAST BAY RETINA CONSULTANTS A MEDICAL GROUP, INC.
Entity Type:Organization
Organization Name:EAST BAY RETINA CONSULTANTS A MEDICAL GROUP, INC.
Other - Org Name:EAST BAY RETINA CONSULTANTS, INC.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CORPORATE VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SOON
Authorized Official - Middle Name:T
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:510-444-1600
Mailing Address - Street 1:3300 TELEGRAPH AVE
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94609-3028
Mailing Address - Country:US
Mailing Address - Phone:510-444-1600
Mailing Address - Fax:510-444-5117
Practice Address - Street 1:5924 STONERIDGE DR
Practice Address - Street 2:SUITE 201
Practice Address - City:PLEASANTON
Practice Address - State:CA
Practice Address - Zip Code:94588-2887
Practice Address - Country:US
Practice Address - Phone:925-224-8777
Practice Address - Fax:925-224-8779
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-13
Last Update Date:2016-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA44312207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty