Provider Demographics
NPI:1619949971
Name:RETINA AND VITREOUS ASSOCIATES OF KENTUCKY PLLC
Entity Type:Organization
Organization Name:RETINA AND VITREOUS ASSOCIATES OF KENTUCKY PLLC
Other - Org Name:RETINA ASSOCIATES OF KENTUCKY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:PRAVOOT
Authorized Official - Last Name:GIRA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:314-909-0633
Mailing Address - Street 1:120 N EAGLE CREEK DR
Mailing Address - Street 2:STE 500
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40509-1827
Mailing Address - Country:US
Mailing Address - Phone:859-263-3900
Mailing Address - Fax:859-263-3757
Practice Address - Street 1:120 N EAGLE CREEK DR
Practice Address - Street 2:STE 500
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40509-1827
Practice Address - Country:US
Practice Address - Phone:859-263-3900
Practice Address - Fax:859-263-3757
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-02
Last Update Date:2023-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
152W00000X, 207WX0107X
KY1689DT152WL0500X
KY207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207WX0107XAllopathic & Osteopathic PhysiciansOphthalmologyRetina SpecialistGroup - Single Specialty
No152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
No152WL0500XEye and Vision Services ProvidersOptometristLow Vision RehabilitationGroup - Single Specialty
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100871660Medicaid
OH0730481Medicaid
KY7100856500Medicaid
WV0007018000Medicaid
IN201209490AMedicaid