Provider Demographics
NPI:1114044435
Name:RETINA & VITREOUS CONSULTANTS OF WI, LTD.
Entity Type:Organization
Organization Name:RETINA & VITREOUS CONSULTANTS OF WI, LTD.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SHARATH
Authorized Official - Middle Name:C
Authorized Official - Last Name:RAJA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:414-774-3484
Mailing Address - Street 1:2600 N MAYFAIR RD
Mailing Address - Street 2:SUITE 901
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226-1309
Mailing Address - Country:US
Mailing Address - Phone:414-774-3484
Mailing Address - Fax:414-778-3445
Practice Address - Street 1:2600 N MAYFAIR RD
Practice Address - Street 2:SUITE 901
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-1309
Practice Address - Country:US
Practice Address - Phone:414-774-3484
Practice Address - Fax:414-778-3445
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-23
Last Update Date:2021-06-23
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
WI32708400Medicaid
WI000001702OtherMEDICARE-MILW COUNTY
WI32708400Medicaid
IL0080000057OtherBCBS IL
WI=========OtherHUMANA
WI=========OtherAETNA
WI=========OtherCIGNA
WI32708400OtherWI BADGER CARE
WV=========016OtherBCS WI
MN=========Medicaid
WI=========OtherAETNA
MN=========Medicaid