Provider Demographics
NPI:1235468513
Name:RETINA INSTITUTE OF NORTH CAROLINA, PC
Entity Type:Organization
Organization Name:RETINA INSTITUTE OF NORTH CAROLINA, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:FOGEL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:919-787-8555
Mailing Address - Street 1:2605 BLUE RIDGE RD
Mailing Address - Street 2:STE 220
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27607-6475
Mailing Address - Country:US
Mailing Address - Phone:919-787-8555
Mailing Address - Fax:919-787-8112
Practice Address - Street 1:3211 ROGERS RD
Practice Address - Street 2:STE 101
Practice Address - City:WAKE FOREST
Practice Address - State:NC
Practice Address - Zip Code:27587-3890
Practice Address - Country:US
Practice Address - Phone:919-453-1462
Practice Address - Fax:919-453-1473
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-15
Last Update Date:2009-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2006-00726207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5903995Medicaid
NC2054856Medicare PIN