Provider Demographics
NPI:1972774917
Name:GENE W ZDENEK A MEDICAL CORPORATION
Entity Type:Organization
Organization Name:GENE W ZDENEK A MEDICAL CORPORATION
Other - Org Name:ZDENEK EYE INSTITUTE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:ZDENEK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:818-708-2222
Mailing Address - Street 1:7012 RESEDA BLVD
Mailing Address - Street 2:SUITE B
Mailing Address - City:RESEDA
Mailing Address - State:CA
Mailing Address - Zip Code:91335-4219
Mailing Address - Country:US
Mailing Address - Phone:818-708-2222
Mailing Address - Fax:
Practice Address - Street 1:7012 RESEDA BLVD
Practice Address - Street 2:SUITE B
Practice Address - City:RESEDA
Practice Address - State:CA
Practice Address - Zip Code:91335-4219
Practice Address - Country:US
Practice Address - Phone:818-708-2222
Practice Address - Fax:818-342-3937
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-18
Last Update Date:2017-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC39161207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00C391610Medicaid
CAA37076Medicare UPIN
CA00C391610Medicaid