Basic Information
| Provider Information | |||||||||
| NPI: | 1225194194 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DOHENY EYE MEDICAL GROUP, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1450 SAN PABLO ST | ||||||||
| Address2: | SUITE 3700 | ||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900334500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3234427152 | ||||||||
| FaxNumber: | 3234427166 | ||||||||
| Practice Location | |||||||||
| Address1: | 40055 BOB HOPE DR | ||||||||
| Address2: | SUITE J | ||||||||
| City: | RANCHO MIRAGE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 922703937 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7603202133 | ||||||||
| FaxNumber: | 7603270495 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/28/2006 | ||||||||
| LastUpdateDate: | 02/27/2008 | ||||||||
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| AuthorizedOfficialLastName: | SMITH | ||||||||
| AuthorizedOfficialFirstName: | RONALD | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | CHAIRMAN | ||||||||
| AuthorizedOfficialTelephone: | 3234426425 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | N | Ambulatory Health Care Facilities | Clinic/Center | 207W00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Ophthalmology |
ID Information
| ID | Type | State | Issuer | Description | ZZZ51610Z | 01 | CA | BLUE SHIELD | OTHER | GR0059892 | 05 | CA | MEDICAID |