Healthcare Provider Details

I. General information

NPI: 1003806068
Provider Name (Legal Business Name): EMPIRE EYE DOCTORS MEDICAL GROUP INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/21/2005
Last Update Date: 05/01/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

720 4TH ST
SANTA ROSA CA
95404-4421
US

IV. Provider business mailing address

720 4TH ST
SANTA ROSA CA
95404-4421
US

V. Phone/Fax

Practice location:
  • Phone: 707-575-3800
  • Fax: 707-528-4967
Mailing address:
  • Phone: 707-575-3800
  • Fax: 707-528-4967

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number8739T
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberT10471
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code152WL0500X
TaxonomyLow Vision Rehabilitation Optometrist
License Number8817T
License Number StateCA
# 4
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberG32243
License Number StateCA
# 5
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberG57122
License Number StateCA
# 6
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberG32019
License Number StateCA

VIII. Authorized Official

Name: PENNY DOW
Title or Position: BILLING MANAGER
Credential:
Phone: 707-575-3800