Provider Demographics
NPI:1457549123
Name:DELTA EYE MEDICAL GROUP, INC.
Entity Type:Organization
Organization Name:DELTA EYE MEDICAL GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CORPORATE CONTROLLER
Authorized Official - Prefix:MS
Authorized Official - First Name:LAURIE
Authorized Official - Middle Name:K
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:209-334-5886
Mailing Address - Street 1:521 S HAM LN
Mailing Address - Street 2:SUITE A
Mailing Address - City:LODI
Mailing Address - State:CA
Mailing Address - Zip Code:95242-3528
Mailing Address - Country:US
Mailing Address - Phone:209-334-5886
Mailing Address - Fax:209-334-5281
Practice Address - Street 1:521 S HAM LN
Practice Address - Street 2:SUITE A
Practice Address - City:LODI
Practice Address - State:CA
Practice Address - Zip Code:95242-3528
Practice Address - Country:US
Practice Address - Phone:209-334-5886
Practice Address - Fax:209-334-5281
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DELTA EYE MEDICAL GROUP, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-10-09
Last Update Date:2023-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACD8211OtherRAILROAD MEDICARE
CAGR0008460Medicaid
CA0681060002Medicare NSC
CACD8211OtherRAILROAD MEDICARE