Provider Demographics
NPI:1134159148
Name:DOHENY EYE MEDICAL GROUP
Entity type:Organization
Organization Name:DOHENY EYE MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:E
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:323-442-6425
Mailing Address - Street 1:1450 SAN PABLO ST
Mailing Address - Street 2:SUITE 3700
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90033-4500
Mailing Address - Country:US
Mailing Address - Phone:323-442-7155
Mailing Address - Fax:323-442-7158
Practice Address - Street 1:1450 SAN PABLO ST
Practice Address - Street 2:SUITE 4000
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90033-4500
Practice Address - Country:US
Practice Address - Phone:323-442-7155
Practice Address - Fax:323-442-7158
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-04
Last Update Date:2008-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0059890Medicaid
CAGR0059891Medicaid
CAGR0059895Medicaid
CAZZZ7157ZOtherBLUE SHIELD
CAGR0059893Medicaid
CAGR0059894Medicaid
CAW11993AMedicare PIN
CAW11993BMedicare PIN
CACD3981Medicare PIN
CAZZZ7157ZOtherBLUE SHIELD
CAGR0059890Medicaid
CAGR0059895Medicaid
CAW11993Medicare PIN