Provider Demographics
NPI:1578892196
Name:RETINA INSTITUTE OF WASHINGTON PLLC
Entity Type:Organization
Organization Name:RETINA INSTITUTE OF WASHINGTON PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:J
Authorized Official - Last Name:KO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:425-228-6262
Mailing Address - Street 1:4300 TALBOT RD S
Mailing Address - Street 2:STE 201
Mailing Address - City:RENTON
Mailing Address - State:WA
Mailing Address - Zip Code:98055-6238
Mailing Address - Country:US
Mailing Address - Phone:425-228-6262
Mailing Address - Fax:425-228-6260
Practice Address - Street 1:4300 TALBOT RD S STE 201
Practice Address - Street 2:
Practice Address - City:RENTON
Practice Address - State:WA
Practice Address - Zip Code:98055-6238
Practice Address - Country:US
Practice Address - Phone:206-892-8281
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-10
Last Update Date:2010-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD60021230207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1205890514OtherNPI-INDIVIDUAL
MD60021230OtherWASHINGTON STATE PROFESSIONAL LICENSE