Provider Demographics
NPI:1962783928
Name:CAPITAL EYE MEDICAL GROUP
Entity type:Organization
Organization Name:CAPITAL EYE MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MITRA
Authorized Official - Middle Name:
Authorized Official - Last Name:AYAZIFAR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:916-960-9176
Mailing Address - Street 1:9221 SIERRA COLLEGE BLVD
Mailing Address - Street 2:SUITE 130
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95661-5919
Mailing Address - Country:US
Mailing Address - Phone:916-797-6747
Mailing Address - Fax:916-797-6728
Practice Address - Street 1:9221 SIERRA COLLEGE BLVD
Practice Address - Street 2:SUITE 130
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95661-5919
Practice Address - Country:US
Practice Address - Phone:916-797-6747
Practice Address - Fax:916-797-6728
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-06
Last Update Date:2019-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC52250207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty