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General NPI Number Information
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NPI Number | 1235168055
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Entity Type | Organization
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Legal Business Name | SAN PEDRO EYE MEDICAL GROUP, INC A PROFESSIONAL MEDICAL CORPORATION
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Dates
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Enumeration Date | 07/02/2006
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Last Update Date | 12/14/2018
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Provider Practice Location Address
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Address Line | 571 W 7TH ST
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City | SAN PEDRO
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State | CA
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Zip | 90731-3115
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Country | US
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Telephone | 310-833-1327
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Fax | 310-833-0698
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Provider Business Mailing Address
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Address Line | 571 W 7TH ST
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City | SAN PEDRO
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State | CA
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Zip | 90731-3115
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Country | US
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Telephone | 310-833-1327
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Fax | 310-833-0698
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Authorized Official
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Title or Position | OWNER/PARTNER
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Name | DR. GENE DAVID CALKINS
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Credential | O.D.
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Telephone | 310-833-1327
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 4919
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License Number State | CA
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Taxonomy #2
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | G14368
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License Number State | CA
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Taxonomy #3
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 7967
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License Number State | CA
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