Provider Demographics
NPI:1790965341
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 1:3300 TELEGRAPH AVE.
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94609-3028
Practice Address - Country:US
Practice Address - Phone:510-444-1600
Practice Address - Fax:510-444-5117
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-13
Last Update Date:2023-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG57682207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ00341ZMedicare PIN