Provider Demographics
NPI:1326089442
Name:RETINA OF COASTAL CAROLINA, PLLC
Entity Type:Organization
Organization Name:RETINA OF COASTAL CAROLINA, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:IGOR
Authorized Official - Middle Name:
Authorized Official - Last Name:WESTRA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:910-254-2023
Mailing Address - Street 1:1801 NEW HANOVER MEDICAL PARK DR
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28403-5351
Mailing Address - Country:US
Mailing Address - Phone:910-254-2023
Mailing Address - Fax:910-254-0242
Practice Address - Street 1:1801 NEW HANOVER MEDICAL PARK DR
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28403-5351
Practice Address - Country:US
Practice Address - Phone:910-254-2023
Practice Address - Fax:910-254-0242
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-09
Last Update Date:2023-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207WX0107XAllopathic & Osteopathic PhysiciansOphthalmologyRetina SpecialistGroup - Single Specialty
No207WX0108XAllopathic & Osteopathic PhysiciansOphthalmologyUveitis and Ocular Inflammatory DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCQPA675Medicaid
NC01315OtherBCBS OF NORTH CAROLINA
NC790129CMedicaid
NC=========002OtherBCBS OF SOUTH CAROLINA
SC=========003OtherBCBS OF SOUTH CAROLINA
NC790129CMedicaid
NC790129CMedicaid
NC2344447Medicare ID - Type UnspecifiedJACKSONVILLE, NC MEDICARE