Basic Information
| Provider Information | |||||||||
| NPI: | 1063172351 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SHARP REES-STEALY MEDICAL GROUP, INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 3075 HEALTH CENTER DR STE 401 | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921232773 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8584992600 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3075 HEALTH CENTER DR STE 401 | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921232773 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8584992600 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/28/2021 | ||||||||
| LastUpdateDate: | 12/28/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GREEN | ||||||||
| AuthorizedOfficialFirstName: | STEVEN | ||||||||
| AuthorizedOfficialMiddleName: | A. | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF MEDICAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 8582626666 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SHARP REES-STEALY MEDICAL GROUP INC | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 12/28/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
No ID Information.