Provider Demographics
NPI:1871783308
Name:EAST BAY OPHTHALMOLOGY
Entity type:Organization
Organization Name:EAST BAY OPHTHALMOLOGY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OPHTHALMOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:E
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:510-724-1768
Mailing Address - Street 1:1700 SAN PABLO AVENUE
Mailing Address - Street 2:SUITE A
Mailing Address - City:PINOLE
Mailing Address - State:CA
Mailing Address - Zip Code:94564
Mailing Address - Country:US
Mailing Address - Phone:510-724-1768
Mailing Address - Fax:888-959-0487
Practice Address - Street 1:1289 PINOLE VALLEY RD
Practice Address - Street 2:
Practice Address - City:PINOLE
Practice Address - State:CA
Practice Address - Zip Code:94564-1348
Practice Address - Country:US
Practice Address - Phone:510-724-1768
Practice Address - Fax:888-959-0487
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-31
Last Update Date:2022-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA87505207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAI58953Medicare UPIN
CA5998930001Medicare NSC
CAZZZ05789ZMedicare UPIN