Provider Demographics
NPI:1275557761
Name:VITREO-RETINAL CONSULTANTS & SURGEONS PA
Entity Type:Organization
Organization Name:VITREO-RETINAL CONSULTANTS & SURGEONS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JUDY
Authorized Official - Middle Name:A
Authorized Official - Last Name:MAREK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:316-683-3108
Mailing Address - Street 1:530 N LORRAINE ST
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67214-4837
Mailing Address - Country:US
Mailing Address - Phone:316-683-5611
Mailing Address - Fax:316-683-0294
Practice Address - Street 1:530 N LORRAINE ST
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67214-4837
Practice Address - Country:US
Practice Address - Phone:316-683-5611
Practice Address - Fax:316-683-0294
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-27
Last Update Date:2018-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS207W00000X
207WX0107X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207WX0107XAllopathic & Osteopathic PhysiciansOphthalmologyRetina SpecialistGroup - Single Specialty
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty