Provider Demographics
NPI:1780633644
Name:EAST BAY EYE CENTERS MEDICAL CORPORATION
Entity Type:Organization
Organization Name:EAST BAY EYE CENTERS MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:TAMMY
Authorized Official - Middle Name:
Authorized Official - Last Name:CARSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:925-830-2112
Mailing Address - Street 1:5801 NORRIS CANYON RD STE 200
Mailing Address - Street 2:
Mailing Address - City:SAN RAMON
Mailing Address - State:CA
Mailing Address - Zip Code:94583-5440
Mailing Address - Country:US
Mailing Address - Phone:925-830-8823
Mailing Address - Fax:925-866-6610
Practice Address - Street 1:5801 NORRIS CANYON ROAD
Practice Address - Street 2:SUITE 200
Practice Address - City:SAN RAMON
Practice Address - State:CA
Practice Address - Zip Code:94583-5406
Practice Address - Country:US
Practice Address - Phone:925-830-8823
Practice Address - Fax:925-866-6610
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-09
Last Update Date:2024-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ05706ZOtherBLUE SHIELD
CAZZZ057067OtherBLUE CROSS
CAZZZ05706ZOtherBLUE SHIELD
CA180046438Medicare ID - Type UnspecifiedRAILROAD MEDICARE
CAZZZ23886ZMedicare PIN