Provider Demographics
NPI:1386710564
Name:DESERT OPHTHALMOLOGY MEDICAL CORPORATION
Entity type:Organization
Organization Name:DESERT OPHTHALMOLOGY MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPHTHALMOLOGY
Authorized Official - Prefix:DR
Authorized Official - First Name:WALLACE
Authorized Official - Middle Name:F
Authorized Official - Last Name:GOLDBAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:760-320-8497
Mailing Address - Street 1:1180 N INDIAN CANYON DR
Mailing Address - Street 2:SUITE W100
Mailing Address - City:PALM SPRINGS
Mailing Address - State:CA
Mailing Address - Zip Code:92262-4834
Mailing Address - Country:US
Mailing Address - Phone:760-320-8497
Mailing Address - Fax:760-320-5444
Practice Address - Street 1:1180 N INDIAN CANYON DR
Practice Address - Street 2:SUITE W100
Practice Address - City:PALM SPRINGS
Practice Address - State:CA
Practice Address - Zip Code:92262-4834
Practice Address - Country:US
Practice Address - Phone:760-320-8497
Practice Address - Fax:760-320-5444
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-28
Last Update Date:2012-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG077969207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
G65381Medicare UPIN
CA1231740001Medicare NSC
CACO827AMedicare PIN