Provider Demographics
NPI:1881726198
Name:SANTA MONICA EYE MEDICAL GROUP
Entity type:Organization
Organization Name:SANTA MONICA EYE MEDICAL GROUP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SHEILA
Authorized Official - Middle Name:D
Authorized Official - Last Name:SIEGAL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-829-5475
Mailing Address - Street 1:1908 SANTA MONICA BLVD
Mailing Address - Street 2:SUITE 3
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90404-1927
Mailing Address - Country:US
Mailing Address - Phone:310-829-5475
Mailing Address - Fax:310-828-1359
Practice Address - Street 1:1908 SANTA MONICA BLVD
Practice Address - Street 2:SUITE 3
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404-1927
Practice Address - Country:US
Practice Address - Phone:310-829-5475
Practice Address - Fax:310-828-1359
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG6556207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ348612Medicaid
CAA57558Medicare UPIN
CAZZZ348612Medicaid