Provider Demographics
NPI:1457497992
Name:VITREO RETINAL CONSULTANTS, PSC
Entity Type:Organization
Organization Name:VITREO RETINAL CONSULTANTS, PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:BOADA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:787-251-5280
Mailing Address - Street 1:1 CALLE RODRIGUEZ SERRA
Mailing Address - Street 2:OLYMPIC TOWER 401
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00907-1496
Mailing Address - Country:US
Mailing Address - Phone:787-251-5280
Mailing Address - Fax:
Practice Address - Street 1:2 AVE. KM 11.3
Practice Address - Street 2:BAYAMON MEDICAL PLAZA SUITE 810
Practice Address - City:BAYAMON
Practice Address - State:PR
Practice Address - Zip Code:00959
Practice Address - Country:US
Practice Address - Phone:787-251-5280
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-30
Last Update Date:2008-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR13255174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR22067Medicare PIN
PR0085242Medicare PIN