Provider Demographics
NPI:1043233133
Name:NORTHEASTERN RETINA, P.C.
Entity Type:Organization
Organization Name:NORTHEASTERN RETINA, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SAMEENA
Authorized Official - Middle Name:
Authorized Official - Last Name:KHAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:918-749-7667
Mailing Address - Street 1:4415 S HARVARD AVE
Mailing Address - Street 2:STE 202
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74135-2620
Mailing Address - Country:US
Mailing Address - Phone:918-749-7667
Mailing Address - Fax:
Practice Address - Street 1:4415 S HARVARD AVE
Practice Address - Street 2:STE 202
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74135-2620
Practice Address - Country:US
Practice Address - Phone:918-749-7667
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty