Provider Demographics
NPI:1790736098
Name:RETINA CONSULTANTS SAN DIEGO INC
Entity Type:Organization
Organization Name:RETINA CONSULTANTS SAN DIEGO INC
Other - Org Name:RETINA CONSULTANTS SAN DIEGO INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JOCELIN
Authorized Official - Middle Name:
Authorized Official - Last Name:ING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:858-500-7815
Mailing Address - Street 1:12630 MONTE VISTA RD
Mailing Address - Street 2:SUITE 104
Mailing Address - City:POWAY
Mailing Address - State:CA
Mailing Address - Zip Code:92064-2526
Mailing Address - Country:US
Mailing Address - Phone:858-451-1911
Mailing Address - Fax:858-451-0566
Practice Address - Street 1:12630 MONTE VISTA RD
Practice Address - Street 2:SUITE 104
Practice Address - City:POWAY
Practice Address - State:CA
Practice Address - Zip Code:92064-2526
Practice Address - Country:US
Practice Address - Phone:858-451-1911
Practice Address - Fax:858-451-0566
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-12
Last Update Date:2024-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADA1466OtherMEDICARE RAILROAD
CAGR0045281Medicaid
CAZZZ30299ZOtherBLUE SHIELD
CAW8585Medicare PIN