Provider Demographics
NPI:1316949506
Name:INSIGHT VISION CENTER MEDICAL GROUP, INC.
Entity type:Organization
Organization Name:INSIGHT VISION CENTER MEDICAL GROUP, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:J
Authorized Official - Last Name:POULSEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:559-449-5050
Mailing Address - Street 1:1360 E HERNDON AVE
Mailing Address - Street 2:STE 201
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93720-3326
Mailing Address - Country:US
Mailing Address - Phone:559-449-5050
Mailing Address - Fax:559-432-2632
Practice Address - Street 1:1360 E HERNDON AVE STE 201
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93720
Practice Address - Country:US
Practice Address - Phone:559-449-5050
Practice Address - Fax:559-432-2632
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-01
Last Update Date:2018-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC1935663207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0078480Medicaid
CAGR0078480Medicaid
CA0218070001Medicare NSC