Healthcare Provider Details

I. General information

NPI: 1154338598
Provider Name (Legal Business Name): RETINA ASSOCIATES MEDICAL GROUP, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/01/2006
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

436 SOUTH GLASSELL ST
ORANGE CA
92866
US

IV. Provider business mailing address

436 SOUTH GLASSELL ST
ORANGE CA
92866
US

V. Phone/Fax

Practice location:
  • Phone: 714-633-6060
  • Fax: 714-633-7470
Mailing address:
  • Phone: 714-633-6060
  • Fax: 714-633-7470

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number
License Number StateCA

VIII. Authorized Official

Name: MR. ROBERT F RUPER
Title or Position: CEO-OWNER
Credential: M.D.
Phone: 714-633-6060