Healthcare Provider Details

I. General information

NPI: 1891264818
Provider Name (Legal Business Name): SAN GABRIEL RETINA PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/19/2018
Last Update Date: 11/05/2024
Certification Date: 11/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

416 W LAS TUNAS DR STE 105
SAN GABRIEL CA
91776-1236
US

IV. Provider business mailing address

416 W LAS TUNAS DR STE 105
SAN GABRIEL CA
91776-1236
US

V. Phone/Fax

Practice location:
  • Phone: 626-262-2082
  • Fax: 626-317-8128
Mailing address:
  • Phone: 626-262-2082
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207WX0107X
TaxonomyRetina Specialist (Ophthalmology) Physician
License Number
License Number State

VIII. Authorized Official

Name: YI JIANG
Title or Position: PRESIDENT
Credential: MD
Phone: 626-262-2082