Provider Demographics
NPI:1124359708
Name:SUMMIT RETINA CONSULTANTS, P.C.
Entity Type:Organization
Organization Name:SUMMIT RETINA CONSULTANTS, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:VELIMIR
Authorized Official - Middle Name:
Authorized Official - Last Name:PETROVIC
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:260-515-2778
Mailing Address - Street 1:6435 W JEFFERSON BLVD # 203
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-6203
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6435 W JEFFERSON BLVD # 203
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-6203
Practice Address - Country:US
Practice Address - Phone:260-515-2778
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-21
Last Update Date:2010-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN50005075A207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty