Basic Information
| Provider Information | |||||||||
| NPI: | 1811284946 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | RETINA VITREOUS CENTER, PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | P.O. BOX 2492 | ||||||||
| Address2: | |||||||||
| City: | EDMOND | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730832492 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4052925500 | ||||||||
| FaxNumber: | 4052925505 | ||||||||
| Practice Location | |||||||||
| Address1: | 1851 S KELLY AVE STE A | ||||||||
| Address2: | |||||||||
| City: | EDMOND | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730133602 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4056076699 | ||||||||
| FaxNumber: | 4056076685 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/10/2011 | ||||||||
| LastUpdateDate: | 10/19/2022 | ||||||||
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| AuthorizedOfficialLastName: | SHAH | ||||||||
| AuthorizedOfficialFirstName: | SANDEEP | ||||||||
| AuthorizedOfficialMiddleName: | N. | ||||||||
| AuthorizedOfficialTitleorPosition: | FOUNDING MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 4056076699 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | 10/19/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207W00000X | 22912 | OK | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Ophthalmology |
ID Information
| ID | Type | State | Issuer | Description | 200198330A | 05 | OK | MEDICAID |