Basic Information
| Provider Information | |||||||||
| NPI: | 1316009103 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | IRVINE | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 STEIN PLZ | ||||||||
| Address2: | 3-236 | ||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900957065 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3102060485 | ||||||||
| FaxNumber: | 3107944930 | ||||||||
| Practice Location | |||||||||
| Address1: | 625 S FAIR OAKS AVE | ||||||||
| Address2: | SUITE 280 | ||||||||
| City: | PASADENA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 911052613 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6268174747 | ||||||||
| FaxNumber: | 6268174702 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/15/2006 | ||||||||
| LastUpdateDate: | 01/15/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207W00000X | G59884 | CA | Y | Allopathic & Osteopathic Physicians | Ophthalmology |
ID Information
| ID | Type | State | Issuer | Description | 006598840 | 05 | CA | MEDICAID | 006598840 | 01 | CA | BLUE SHIELD | OTHER | 180037512 | 01 | CA | MEDICARE RAILROAD | OTHER |