Basic Information
| Provider Information | |||||||||
| NPI: | 1134178460 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | VITREORETINAL ASSOCIATES PLLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | VITREORETINAL ASSOCIATES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1221 MADISON ST | ||||||||
| Address2: | SUITE 1002 | ||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981043588 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2062153850 | ||||||||
| FaxNumber: | 2062153870 | ||||||||
| Practice Location | |||||||||
| Address1: | 1221 MADISON ST | ||||||||
| Address2: | SUITE 1002 | ||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981043588 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2062153850 | ||||||||
| FaxNumber: | 2062153870 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/05/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | WELLS | ||||||||
| AuthorizedOfficialFirstName: | CRAIG | ||||||||
| AuthorizedOfficialMiddleName: | G | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 2062153850 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207W00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Ophthalmology |
ID Information
| ID | Type | State | Issuer | Description | 7081888 | 05 | WA | MEDICAID |