MEDICARE: RETINA INSTITUTE OF CALIFORNIA MEDICAL GROUP, A CALIFORNIA MEDICAL PAR

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	A69909	CA
2	207W00000X	Ophthalmology Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1760541569	OTHER	CA	GROUP NPI

General Provider Information

NPI Number	:	1902299068
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RETINA INSTITUTE OF CALIFORNIA MEDICAL GROUP, A CALIFORNIA MEDICAL PAR

Provider Business Mailing Address
First Line	:	100 E CALIFORNIA BLVD
Second Line	:
City	:	PASADENA
State	:	CA
Zip	:	91105-3205
Country	:	US
Telephone Number	:	626-568-8838
Fax Number	:	626-574-7188

Provider Business Practice Location Address
First Line	:	1950 SUNNY CREST DR STE 3200
Second Line	:
City	:	FULLERTON
State	:	CA
Zip	:	92835-3641
Country	:	US
Telephone Number	:	714-278-1834
Fax Number	:	714-278-1839

Authorized Official
Title or Position	:	FOUNDER
Name	:	DR. TOM S CHANG
Credential	:	MD
Telephone Number	:	626-568-8838

Provider Enumeration Date	:	03/13/2015
Last Update Date	:	06/09/2022

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