Provider Demographics
NPI:1134304884
Name:RETINA MACULA SPECIALISTS PLLC
Entity Type:Organization
Organization Name:RETINA MACULA SPECIALISTS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JAIME
Authorized Official - Middle Name:
Authorized Official - Last Name:MEMBRENO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:407-931-1510
Mailing Address - Street 1:720 W OAK ST
Mailing Address - Street 2:SUITE 301
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34741-4989
Mailing Address - Country:US
Mailing Address - Phone:407-931-1510
Mailing Address - Fax:407-931-3759
Practice Address - Street 1:720 W OAK ST
Practice Address - Street 2:SUITE 301
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34741-4989
Practice Address - Country:US
Practice Address - Phone:407-931-1510
Practice Address - Fax:407-931-3759
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-31
Last Update Date:2011-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLAB492OtherMDCRE PROVIDER #