Healthcare Provider Details

I. General information

NPI: 1225349988
Provider Name (Legal Business Name): SANTA MONICA BAY PHYSICIANS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/28/2010
Last Update Date: 06/28/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1807 WILSHIRE BLVD SUITE 203
SANTA MONICA CA
90403-5652
US

IV. Provider business mailing address

6029 BRISTOL PKWY SUITE 100
CULVER CITY CA
90230-6643
US

V. Phone/Fax

Practice location:
  • Phone: 310-829-0160
  • Fax: 310-829-0170
Mailing address:
  • Phone: 310-417-5900
  • Fax: 310-410-1001

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPT 12279 TPL
License Number StateCA

VIII. Authorized Official

Name: BERNARD J KATZ
Title or Position: CO-CEO
Credential: MD
Phone: 310-417-5900