Provider Demographics
NPI:1699392506
Name:DESERT OPHTHALMOLOGY MEDICAL CORPORATION
Entity Type:Organization
Organization Name:DESERT OPHTHALMOLOGY MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WALLACE
Authorized Official - Middle Name:FRANKLIN
Authorized Official - Last Name:GOLDBAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:760-320-8497
Mailing Address - Street 1:72650 FRED WARING DR STE 109
Mailing Address - Street 2:
Mailing Address - City:PALM DESERT
Mailing Address - State:CA
Mailing Address - Zip Code:92260-5008
Mailing Address - Country:US
Mailing Address - Phone:760-776-8600
Mailing Address - Fax:
Practice Address - Street 1:72650 FRED WARING DR STE 109
Practice Address - Street 2:
Practice Address - City:PALM DESERT
Practice Address - State:CA
Practice Address - Zip Code:92260-5008
Practice Address - Country:US
Practice Address - Phone:760-776-8600
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-06-26
Last Update Date:2020-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty