Provider Demographics
NPI:1720101876
Name:MARSHALL B. KETCHUM UNIVERSITY
Entity Type:Organization
Organization Name:MARSHALL B. KETCHUM UNIVERSITY
Other - Org Name:UNIVERSITY EYE CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:ASSOCIATE DEAN OF CLINICS
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:NAKANO
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:714-463-7504
Mailing Address - Street 1:5460 E LA PALMA AVE
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92807-2023
Mailing Address - Country:US
Mailing Address - Phone:714-463-7500
Mailing Address - Fax:714-992-7811
Practice Address - Street 1:5460 E LA PALMA AVE
Practice Address - Street 2:
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92807-2023
Practice Address - Country:US
Practice Address - Phone:714-463-7500
Practice Address - Fax:714-992-7811
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-06
Last Update Date:2016-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACP8428OtherRAILROAD
CAZZT11708FMedicaid
CAZZT11708FMedicaid
CA0368540002Medicare NSC
CAW16115Medicare UPIN