Provider Demographics
NPI:1013452572
Name:RETINA INSTITUTE OF CALIFORNIA MEDICAL GROUP
Entity Type:Organization
Organization Name:RETINA INSTITUTE OF CALIFORNIA MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TOM
Authorized Official - Middle Name:S
Authorized Official - Last Name:CHANG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:626-568-8838
Mailing Address - Street 1:100 E CALIFORNIA BLVD
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91105-3205
Mailing Address - Country:US
Mailing Address - Phone:626-269-5357
Mailing Address - Fax:626-574-7188
Practice Address - Street 1:58471 29 PALMS HWY
Practice Address - Street 2:203
Practice Address - City:YUCCA VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92284-5818
Practice Address - Country:US
Practice Address - Phone:760-853-3005
Practice Address - Fax:760-853-3012
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-19
Last Update Date:2021-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
No152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1760541569Medicaid
CABW463AMedicare PIN