Provider Demographics
NPI:1518212760
Name:TAMPA BAY RETINA, PA
Entity Type:Organization
Organization Name:TAMPA BAY RETINA, PA
Other - Org Name:GULF COAST RETINA CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:OREN
Authorized Official - Middle Name:
Authorized Official - Last Name:PLOUS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:248-790-5111
Mailing Address - Street 1:1961 FLOYD ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34239-2931
Mailing Address - Country:US
Mailing Address - Phone:941-312-2769
Mailing Address - Fax:866-426-2169
Practice Address - Street 1:1961 FLOYD ST
Practice Address - Street 2:SUITE B
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34239
Practice Address - Country:US
Practice Address - Phone:941-312-2769
Practice Address - Fax:941-759-6476
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-13
Last Update Date:2022-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME97145207WX0107X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207WX0107XAllopathic & Osteopathic PhysiciansOphthalmologyRetina SpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLP01531788OtherPALMETTO GBA-RAILROAD MEDICARE
FL91135OtherBCBS OF FLORIDA
FLP01406413OtherPALMETTO GBA RAILROAD MCR
FLP01531788OtherPALMETTO GBA-RAILROAD MEDICARE
FLGL151BMedicare PIN
FLAB951NMedicare PIN
FLP01406413OtherPALMETTO GBA RAILROAD MCR
FL277086500Medicaid
FLAB951XMedicare PIN
FLAB951OMedicare PIN
FLAB951TMedicare PIN