Provider Demographics
NPI:1912058728
Name:A CENTER FOR VISIONCARE SURGICAL & MEDICAL GROUP
Entity Type:Organization
Organization Name:A CENTER FOR VISIONCARE SURGICAL & MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DANA
Authorized Official - Middle Name:I
Authorized Official - Last Name:TANNENBAUM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-762-0647
Mailing Address - Street 1:4418 VINELAND AVE
Mailing Address - Street 2:106
Mailing Address - City:NORTH HOLLYWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:91602-3457
Mailing Address - Country:US
Mailing Address - Phone:818-762-0647
Mailing Address - Fax:818-762-7834
Practice Address - Street 1:2031 W ALAMEDA AVE STE 300
Practice Address - Street 2:
Practice Address - City:BURBANK
Practice Address - State:CA
Practice Address - Zip Code:91506-2960
Practice Address - Country:US
Practice Address - Phone:818-762-0647
Practice Address - Fax:818-762-7834
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-16
Last Update Date:2022-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
No152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ39782ZOtherBLUE SHIELD
CAGR0059240Medicaid
CAGSD001470Medicaid
CAGR0059240Medicaid
CA0795490001Medicare NSC
CAW12238Medicare PIN