Provider Demographics
NPI:1154303055
Name:RETINA CONSULTANTS PA
Entity Type:Organization
Organization Name:RETINA CONSULTANTS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:MILTON
Authorized Official - Last Name:COWAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:817-332-1782
Mailing Address - Street 1:909 9TH AVENUE
Mailing Address - Street 2:#404
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-3918
Mailing Address - Country:US
Mailing Address - Phone:817-332-1782
Mailing Address - Fax:817-336-8619
Practice Address - Street 1:909 9TH AVENUE
Practice Address - Street 2:SUTIE 404
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-3918
Practice Address - Country:US
Practice Address - Phone:817-332-1782
Practice Address - Fax:817-336-8619
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-16
Last Update Date:2010-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX082344501Medicaid
=========OtherCOMMERCIAL INS
TX00ES31Medicare PIN