Healthcare Provider Details

I. General information

NPI: 1457744534
Provider Name (Legal Business Name): RETINA INSTITUTE OF CALIFORNIA MEDICAL GROUP, A CALIFORNIA MEDICAL PAR
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/12/2015
Last Update Date: 04/01/2022
Certification Date: 04/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9500 STOCKDALE HWY STE. 108
BAKERSFIELD CA
93311-3620
US

IV. Provider business mailing address

100 E CALIFORNIA BLVD
PASADENA CA
91105-3205
US

V. Phone/Fax

Practice location:
  • Phone: 661-663-8500
  • Fax: 661-663-8688
Mailing address:
  • Phone: 626-568-8838
  • Fax: 626-574-7188

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberA69909
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License NumberA69909
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. TOM S CHANG
Title or Position: CEO
Credential: MD
Phone: 626-568-8838