MEDICARE: EYEMD ON CASS A PROFESSIONAL CORPORATION

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	12298T	CA

General Provider Information

NPI Number	:	1205095742
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EYEMD ON CASS A PROFESSIONAL CORPORATION

Provider Business Mailing Address
First Line	:	880 CASS ST
Second Line	:	#105
City	:	MONTEREY
State	:	CA
Zip	:	93940-2947
Country	:	US
Telephone Number	:	831-373-0183
Fax Number	:	831-886-3366

Provider Business Practice Location Address
First Line	:	880 CASS ST
Second Line	:	#105
City	:	MONTEREY
State	:	CA
Zip	:	93940-2947
Country	:	US
Telephone Number	:	831-373-0183
Fax Number	:	831-373-2275

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. PHILIP J PENROSE
Credential	:	MD
Telephone Number	:	831-324-4730

Provider Enumeration Date	:	06/09/2008
Last Update Date	:	03/15/2017

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