Provider Demographics
NPI:1194803320
Name:ORANGE COUNTY OPHTHALMOLOGY MEDICAL GROUP
Entity type:Organization
Organization Name:ORANGE COUNTY OPHTHALMOLOGY MEDICAL GROUP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:RUTH
Authorized Official - Middle Name:
Authorized Official - Last Name:GASSO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:714-534-8373
Mailing Address - Street 1:12665 GARDEN GROVE BLVD
Mailing Address - Street 2:SUITE 401
Mailing Address - City:GARDEN GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:92843-1901
Mailing Address - Country:US
Mailing Address - Phone:714-534-8373
Mailing Address - Fax:714-534-8759
Practice Address - Street 1:12665 GARDEN GROVE BLVD
Practice Address - Street 2:SUITE 401
Practice Address - City:GARDEN GROVE
Practice Address - State:CA
Practice Address - Zip Code:92843-1901
Practice Address - Country:US
Practice Address - Phone:714-534-8373
Practice Address - Fax:714-534-8759
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-02
Last Update Date:2016-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAS051061Medicare PIN