Provider Demographics
NPI:1952582330
Name:SPECIALTY MEDICAL GROUP CENTRAL CALIFORNIA - DEPT OF OPHTHALMOLOGY
Entity type:Organization
Organization Name:SPECIALTY MEDICAL GROUP CENTRAL CALIFORNIA - DEPT OF OPHTHALMOLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT AND MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:RALPH
Authorized Official - Middle Name:P
Authorized Official - Last Name:DIAZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:559-353-5016
Mailing Address - Street 1:9300 VALLEY CHILDRENS PL
Mailing Address - Street 2:
Mailing Address - City:MADERA
Mailing Address - State:CA
Mailing Address - Zip Code:93636-8761
Mailing Address - Country:US
Mailing Address - Phone:559-353-7271
Mailing Address - Fax:559-353-5426
Practice Address - Street 1:9300 VALLEY CHILDRENS PL
Practice Address - Street 2:GE01
Practice Address - City:MADERA
Practice Address - State:CA
Practice Address - Zip Code:93636-8761
Practice Address - Country:US
Practice Address - Phone:559-353-7271
Practice Address - Fax:559-353-5426
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SPECIALTY MEDICAL GROUP CENTRAL CALIFORNIA, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-11-14
Last Update Date:2007-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0078980Medicaid
ZZZ13884ZMedicare PIN