MEDICARE: EYECARE SPECIALISTS MEDICAL GROUP, INC

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	207W00000X	Ophthalmology Physician

General Provider Information

NPI Number	:	1669246104
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EYECARE SPECIALISTS MEDICAL GROUP, INC

Provider Business Mailing Address
First Line	:	14726 RAMONA AVE STE 203
Second Line	:
City	:	CHINO
State	:	CA
Zip	:	91710-5730
Country	:	US
Telephone Number	:	626-305-9100
Fax Number	:	626-305-0152

Provider Business Practice Location Address
First Line	:	7677 CENTER AVE STE 102
Second Line	:
City	:	HUNTINGTON BEACH
State	:	CA
Zip	:	92647-3030
Country	:	US
Telephone Number	:	714-316-0802
Fax Number	:	714-316-0804

Authorized Official
Title or Position	:	MEDICAL DIRECTOR
Name	:	DWAYNE K LOGAN
Credential	:
Telephone Number	:	562-938-9945

Provider Enumeration Date	:	11/14/2023
Last Update Date	:	11/14/2023

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