Healthcare Provider Details

I. General information

NPI: 1518480615
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: 07/20/2017
Last Update Date: 01/19/2022
Certification Date: 01/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

435 ARDEN AVE STE 430
GLENDALE CA
91203-4022
US

IV. Provider business mailing address

100 E CALIFORNIA BLVD
PASADENA CA
91105-3205
US

V. Phone/Fax

Practice location:
  • Phone: 818-539-8016
  • Fax: 818-351-3657
Mailing address:
  • Phone: 626-568-8838
  • Fax: 626-583-8838

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number
License Number StateCA

VIII. Authorized Official

Name: TOM S CHANG
Title or Position: FOUNDER
Credential: MD
Phone: 626-568-8838