Healthcare Provider Details

I. General information

NPI: 1134588932
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: 02/22/2016
Last Update Date: 04/06/2022
Certification Date: 04/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1640 NEWPORT BLVD STE 220
COSTA MESA CA
92627-3786
US

IV. Provider business mailing address

100 E CALIFORNIA BLVD
PASADENA CA
91105-3205
US

V. Phone/Fax

Practice location:
  • Phone: 949-876-5046
  • Fax: 949-573-5394
Mailing address:
  • Phone: 800-898-2020
  • Fax: 626-577-2100

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: TOM CHANG
Title or Position: FOUNDER/OWNER
Credential:
Phone: 626-568-8838