Provider Demographics
NPI:1326307083
Name:RETINA ASSOCIATES OF SOUTHERN UTAH
Entity Type:Organization
Organization Name:RETINA ASSOCIATES OF SOUTHERN UTAH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:GAYEA
Authorized Official - Middle Name:
Authorized Official - Last Name:ESPLIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:435-216-7032
Mailing Address - Street 1:PO BOX 911810
Mailing Address - Street 2:
Mailing Address - City:ST GEORGE
Mailing Address - State:UT
Mailing Address - Zip Code:84791-1810
Mailing Address - Country:US
Mailing Address - Phone:435-216-7032
Mailing Address - Fax:866-836-9639
Practice Address - Street 1:585 E RIVERSIDE DRIVE
Practice Address - Street 2:SUITE 201
Practice Address - City:ST GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84790
Practice Address - Country:US
Practice Address - Phone:435-216-7032
Practice Address - Fax:866-836-9639
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-15
Last Update Date:2022-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ154615Medicare PIN
U000076079Medicare UPIN
NVGG486AMedicare PIN