# EMPIRE EYE DOCTORS MEDICAL GROUP INC

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1003806068
- **Authorized official:** PENNY DOW (BILLING MANAGER)
- **Authorized official phone:** (707) 575-3800

## Contact information

- **Practice address:** 720 4TH ST, SANTA ROSA, CA 95404-4421
- **Practice address phone:** (707) 575-3800
- **Practice address fax:** (707) 528-4967
- **Mailing address:** 720 4TH ST, SANTA ROSA, CA 95404-4421
- **Mailing address phone:** (707) 575-3800
- **Mailing address fax:** (707) 528-4967

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 152W00000X | Optometrist | 8739T | CA | — |
| 152W00000X | Optometrist | T10471 | CA | — |
| 152WL0500X | Low Vision Rehabilitation Optometrist | 8817T | CA | — |
| 207W00000X | Ophthalmology Physician | G32019 | CA | — |
| 207W00000X | Ophthalmology Physician | G32243 | CA | Yes |
| 207W00000X | Ophthalmology Physician | G57122 | CA | — |

## Other

- **Enumeration date:** 10/21/2005
- **Last updated:** 05/01/2008

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 01 | — | CP5395 | RAILROAD MEDICARE | CA |
| 05 | — | GR0016130 | — | CA |