Provider Demographics
NPI:1134588932
Name:RETINA INSTITUTE OF CALIFORNIA MEDICAL GROUP, A CALIFORNIA MEDICAL PAR
Entity type:Organization
Organization Name:RETINA INSTITUTE OF CALIFORNIA MEDICAL GROUP, A CALIFORNIA MEDICAL PAR
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:FOUNDER/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TOM
Authorized Official - Middle Name:
Authorized Official - Last Name:CHANG
Authorized Official - Suffix:
Authorized Official - Credentials:
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:800-898-2020
Mailing Address - Fax:626-577-2100
Practice Address - Street 1:1640 NEWPORT BLVD STE 220
Practice Address - Street 2:
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92627-3786
Practice Address - Country:US
Practice Address - Phone:949-876-5046
Practice Address - Fax:949-573-5394
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-22
Last Update Date:2022-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA69909152W00000X, 207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
No152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW20602Medicare PIN