Healthcare Provider Details

I. General information

NPI: 1235231598
Provider Name (Legal Business Name): EYE PHYSICIANS OF LONG BEACH A MEDICAL GROUP INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/05/2006
Last Update Date: 08/24/2021
Certification Date: 08/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2925 PALO VERDE AVE
LONG BEACH CA
90815-1552
US

IV. Provider business mailing address

2925 PALO VERDE AVE
LONG BEACH CA
90815-1552
US

V. Phone/Fax

Practice location:
  • Phone: 562-421-2757
  • Fax: 562-420-7267
Mailing address:
  • Phone: 562-421-2757
  • Fax: 562-420-7267

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPT8329TPA
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberA68745
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberG84806
License Number StateCA

VIII. Authorized Official

Name: CARLOS ENRIQUE MARTINEZ
Title or Position: OWNER
Credential: MD
Phone: 562-421-2757