Basic Information
| Provider Information | |||||||||
| NPI: | 1619949971 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | RETINA AND VITREOUS ASSOCIATES OF KENTUCKY PSC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | LOW VISION SERVICES OF KY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 120 N EAGLE CREEK DR | ||||||||
| Address2: | STE 500 | ||||||||
| City: | LEXINGTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 405091827 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8592633900 | ||||||||
| FaxNumber: | 8592633757 | ||||||||
| Practice Location | |||||||||
| Address1: | 120 N EAGLE CREEK DR | ||||||||
| Address2: | STE 500 | ||||||||
| City: | LEXINGTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 405091827 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8592633900 | ||||||||
| FaxNumber: | 8592633757 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/02/2006 | ||||||||
| LastUpdateDate: | 07/27/2022 | ||||||||
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| AuthorizedOfficialLastName: | GIRA | ||||||||
| AuthorizedOfficialFirstName: | JOSEPH | ||||||||
| AuthorizedOfficialMiddleName: | PRAVOOT | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 3149090633 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 07/21/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist | 152WL0500X | 1689DT | KY | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist | Low Vision Rehabilitation | 207WX0107X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | 207W00000X | KY | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Ophthalmology |
ID Information
| ID | Type | State | Issuer | Description | 201209490A | 05 | IN | MEDICAID | 65914236 | 05 | KY | MEDICAID | 0007018000 | 05 | WV | MEDICAID | 0730481 | 05 | OH | MEDICAID |