Provider Demographics
NPI:1639252000
Name:RETINA & VITREOUS CENTER PC
Entity Type:Organization
Organization Name:RETINA & VITREOUS CENTER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ALAN
Authorized Official - Middle Name:L
Authorized Official - Last Name:WAGNER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:757-481-4400
Mailing Address - Street 1:6160 KEMPSVILLE CIR STE 250B
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23502-3933
Mailing Address - Country:US
Mailing Address - Phone:757-481-4400
Mailing Address - Fax:757-481-1285
Practice Address - Street 1:6160 KEMPSVILLE CIR STE 120B
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23502-3933
Practice Address - Country:US
Practice Address - Phone:757-481-4400
Practice Address - Fax:757-481-1285
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-22
Last Update Date:2019-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101039260174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA006396097Medicaid
VA006396097Medicaid