Healthcare Provider Details

I. General information

NPI: 1790928067
Provider Name (Legal Business Name): BAY AREA RETINA ASSOCIATES, MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/15/2009
Last Update Date: 05/23/2021
Certification Date: 05/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1460 N CAMINO ALTO STE 206
VALLEJO CA
94589-2567
US

IV. Provider business mailing address

365 LENNON LN STE 250
WALNUT CREEK CA
94598-5915
US

V. Phone/Fax

Practice location:
  • Phone: 707-552-9596
  • Fax: 707-552-9599
Mailing address:
  • Phone: 925-265-8324
  • Fax: 925-522-8658

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: AGNES MERCADO
Title or Position: DIRECTOR OF REVENUE CYCLE
Credential: CRCS
Phone: 925-265-8324