Basic Information
| Provider Information | |||||||||
| NPI: | 1265986699 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | THE EYELID DOC, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 20831 | ||||||||
| Address2: | |||||||||
| City: | BAKERSFIELD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 933900831 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6613253937 | ||||||||
| FaxNumber: | 6612833937 | ||||||||
| Practice Location | |||||||||
| Address1: | 5901 ENCINA RD STE C3 | ||||||||
| Address2: | |||||||||
| City: | GOLETA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 931172272 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8055655700 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/15/2016 | ||||||||
| LastUpdateDate: | 08/15/2016 | ||||||||
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| AuthorizedOfficialLastName: | CHANG | ||||||||
| AuthorizedOfficialFirstName: | JOSEPH | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 661325393937 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207W00000X | A29218 | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Ophthalmology |
ID Information
| ID | Type | State | Issuer | Description | 1306959259 | 05 | CA | MEDICAID |