Provider Demographics
NPI:1457492167
Name:RETINA INSTITUTE OF INDIANA, P.C.
Entity Type:Organization
Organization Name:RETINA INSTITUTE OF INDIANA, P.C.
Other - Org Name:VITREORETINAL CONSULTANTS OF FORT WAYNE, P.C.
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GOHAR
Authorized Official - Middle Name:AZAM
Authorized Official - Last Name:SALAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:260-483-9500
Mailing Address - Street 1:11188 DIEBOLD RD.
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-1712
Mailing Address - Country:US
Mailing Address - Phone:260-483-9500
Mailing Address - Fax:260-483-9511
Practice Address - Street 1:11188 DIEBOLD RD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46845-9662
Practice Address - Country:US
Practice Address - Phone:260-483-9500
Practice Address - Fax:260-483-9511
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-08
Last Update Date:2016-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN50004672A207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000364631OtherANTHEM BLUE CROSS
IN17842OtherPHP
IN200522580AMedicaid
IN7800696OtherAETNA
IN200522580AMedicaid
INDF2992Medicare PIN