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General NPI Number Information
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NPI Number | 1720644081
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Entity Type | Organization
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Legal Business Name | RETINA INSTITUTE OF CALIFORNIA MEDICAL GROUP, A CALIFORNIA MEDICAL PAR
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Dates
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Enumeration Date | 05/13/2019
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Last Update Date | 03/30/2021
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Provider Practice Location Address
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Address Line | 1360 W 6TH ST STE 165
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City | SAN PEDRO
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State | CA
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Zip | 90732-3540
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Country | US
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Telephone | 800-898-2020
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Fax | 949-538-3938
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Provider Business Mailing Address
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Address Line | 100 E CALIFORNIA BLVD
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City | PASADENA
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State | CA
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Zip | 91105-3205
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Country | US
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Telephone | 800-898-2020
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | TOM S CHANG
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Credential | MD
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Telephone | 800-898-2020
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207W00000X
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Taxonomy Name | Ophthalmology Physician
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number |
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License Number State |
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