Provider Demographics
NPI:1700807815
Name:RETINAL CONSULTANTS OF SOUTHERN CALIFORNIA MEDICAL GROUP, INC
Entity Type:Organization
Organization Name:RETINAL CONSULTANTS OF SOUTHERN CALIFORNIA MEDICAL GROUP, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:DIDDIE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:805-379-0200
Mailing Address - Street 1:1220 LA VENTA DR
Mailing Address - Street 2:SUITE 211
Mailing Address - City:WESTLAKE VILLAGE
Mailing Address - State:CA
Mailing Address - Zip Code:91361-3703
Mailing Address - Country:US
Mailing Address - Phone:805-379-0200
Mailing Address - Fax:805-496-5204
Practice Address - Street 1:1220 LA VENTA DR
Practice Address - Street 2:SUITE 211
Practice Address - City:WESTLAKE VILLAGE
Practice Address - State:CA
Practice Address - Zip Code:91361-3703
Practice Address - Country:US
Practice Address - Phone:805-379-0200
Practice Address - Fax:805-496-5204
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-22
Last Update Date:2023-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG33939174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACP5288OtherRAILROAD MEDICARE
CA00G339391Medicaid
CA00G339391Medicaid
CAW9962Medicare PIN