Provider Demographics
NPI:1114010949
Name:VITREO-RETINAL MEDICAL GROUP, INC.
Entity Type:Organization
Organization Name:VITREO-RETINAL MEDICAL GROUP, INC.
Other - Org Name:MODESTO RETINA CENTER, INC.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOEL
Authorized Official - Middle Name:
Authorized Official - Last Name:PEARLMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:916-596-2027
Mailing Address - Street 1:3 PARK CENTER DR STE 210
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95825-8341
Mailing Address - Country:US
Mailing Address - Phone:916-596-2027
Mailing Address - Fax:866-913-6557
Practice Address - Street 1:4712 STODDARD RD
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95356-9404
Practice Address - Country:US
Practice Address - Phone:209-549-8444
Practice Address - Fax:209-549-8443
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-02
Last Update Date:2023-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207WX0107XAllopathic & Osteopathic PhysiciansOphthalmologyRetina SpecialistGroup - Single Specialty
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACP5300OtherRAILROAD MEDICARE
CAZZZ32011ZOtherWORKERS COMP
WA0199873OtherDEPT. OF LABOR WA
CAGR0030323Medicaid
CAZZZ29020ZOtherBLUE SHIELD CA
CAZZZ29020ZOtherBLUE SHIELD CA