Provider Demographics
NPI:1366562613
Name:EDUARDO P MACIAS, MD, INC.
Entity type:Organization
Organization Name:EDUARDO P MACIAS, MD, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:EDUARDO
Authorized Official - Middle Name:P
Authorized Official - Last Name:MACIAS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:909-933-0622
Mailing Address - Street 1:18066 FOOTHILL BLVD
Mailing Address - Street 2:
Mailing Address - City:FONTANA
Mailing Address - State:CA
Mailing Address - Zip Code:92335-8503
Mailing Address - Country:US
Mailing Address - Phone:909-933-0622
Mailing Address - Fax:909-427-8903
Practice Address - Street 1:18066 FOOTHILL BLVD
Practice Address - Street 2:
Practice Address - City:FONTANA
Practice Address - State:CA
Practice Address - Zip Code:92335-8503
Practice Address - Country:US
Practice Address - Phone:909-427-8900
Practice Address - Fax:909-427-8903
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-30
Last Update Date:2018-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA86739207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA86739OtherPRESIDENTS STATE LIC#
CAI13389Medicare UPIN