Provider Demographics
NPI:1649332990
Name:PENINSULA LASER EYE MEDICAL GROUP, INC
Entity type:Organization
Organization Name:PENINSULA LASER EYE MEDICAL GROUP, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:J
Authorized Official - Last Name:BEERS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:650-961-2585
Mailing Address - Street 1:1174 CASTRO ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:MOUNTAIN VIEW
Mailing Address - State:CA
Mailing Address - Zip Code:94040-2568
Mailing Address - Country:US
Mailing Address - Phone:650-961-2585
Mailing Address - Fax:650-961-6527
Practice Address - Street 1:1174 CASTRO ST
Practice Address - Street 2:SUITE 100
Practice Address - City:MOUNTAIN VIEW
Practice Address - State:CA
Practice Address - Zip Code:94040-2568
Practice Address - Country:US
Practice Address - Phone:650-961-2585
Practice Address - Fax:650-961-6527
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-14
Last Update Date:2015-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CK5784OtherRAILROAD MEDICARE
CAGR0093380Medicaid
ZZZ05868ZOtherBLUE SHIELD CA
CK5784OtherRAILROAD MEDICARE