Provider Demographics
NPI:1518609429
Name:INDIANA RETINA CENTER LLC
Entity Type:Organization
Organization Name:INDIANA RETINA CENTER LLC
Other - Org Name:INDIANA RETINA CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:DAEOK
Authorized Official - Last Name:KIM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:410-967-7322
Mailing Address - Street 1:7802 W JEFFERSON BLVD STE A
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-4138
Mailing Address - Country:US
Mailing Address - Phone:260-305-2822
Mailing Address - Fax:
Practice Address - Street 1:7802 W JEFFERSON BLVD STE A
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-4138
Practice Address - Country:US
Practice Address - Phone:410-967-7322
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-04-11
Last Update Date:2022-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207WX0107XAllopathic & Osteopathic PhysiciansOphthalmologyRetina SpecialistGroup - Single Specialty