Provider Demographics
NPI:1538259049
Name:POLARIS EYE & LASER, A MEDICAL CORPORATION
Entity type:Organization
Organization Name:POLARIS EYE & LASER, A MEDICAL CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JEEHEE
Authorized Official - Middle Name:
Authorized Official - Last Name:KIM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:408-358-3932
Mailing Address - Street 1:2505 SAMARITAN DR
Mailing Address - Street 2:SUITE 310
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95124-4006
Mailing Address - Country:US
Mailing Address - Phone:408-358-3932
Mailing Address - Fax:408-358-3935
Practice Address - Street 1:2505 SAMARITAN DR
Practice Address - Street 2:SUITE 310
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95124-4006
Practice Address - Country:US
Practice Address - Phone:408-358-3932
Practice Address - Fax:408-358-3935
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-13
Last Update Date:2007-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG84931261QS0132X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS0132XAmbulatory Health Care FacilitiesClinic/CenterOphthalmologic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
G30653Medicare UPIN
CA5886210001Medicare NSC