Provider Demographics
NPI:1104045202
Name:RETINA ASSOCIATES PC
Entity Type:Organization
Organization Name:RETINA ASSOCIATES PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:DONALD
Authorized Official - Last Name:HAYNIE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:701-277-4699
Mailing Address - Street 1:PO BOX 11247
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58106-1247
Mailing Address - Country:US
Mailing Address - Phone:701-277-4699
Mailing Address - Fax:701-277-8357
Practice Address - Street 1:4642 AMBER VALLEY PKWY S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58104-8612
Practice Address - Country:US
Practice Address - Phone:701-277-4699
Practice Address - Fax:701-277-8357
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-25
Last Update Date:2007-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND6710207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND11166Medicaid
ND11166Medicaid