Provider Demographics
NPI:1922713395
Name:CENTRO OFTALMOLOGICO SAN ANGEL
Entity Type:Organization
Organization Name:CENTRO OFTALMOLOGICO SAN ANGEL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MGR
Authorized Official - Prefix:
Authorized Official - First Name:JAVIER
Authorized Official - Middle Name:
Authorized Official - Last Name:EZQUERRA
Authorized Official - Suffix:
Authorized Official - Credentials:DR
Authorized Official - Phone:888-449-7799
Mailing Address - Street 1:500 WESTOVER DR # 19593
Mailing Address - Street 2:
Mailing Address - City:SANFORD
Mailing Address - State:NC
Mailing Address - Zip Code:27330-8941
Mailing Address - Country:US
Mailing Address - Phone:888-449-7799
Mailing Address - Fax:
Practice Address - Street 1:CALLE SANTA MONICA 430-435
Practice Address - Street 2:COL EL SANTUARIO
Practice Address - City:GUADALAJARA
Practice Address - State:MX
Practice Address - Zip Code:44200
Practice Address - Country:MX
Practice Address - Phone:888-449-7799
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-01-19
Last Update Date:2023-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS0132XAmbulatory Health Care FacilitiesClinic/CenterOphthalmologic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
56738497905909OtherSTATE