Provider Demographics
NPI:1639306665
Name:RETINA ASSOCIATES, PSC
Entity Type:Organization
Organization Name:RETINA ASSOCIATES, PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EMPLOYEE DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:LEON
Authorized Official - Last Name:JAGGERS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:502-589-1500
Mailing Address - Street 1:1536 STORY AVE
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40206-1738
Mailing Address - Country:US
Mailing Address - Phone:502-589-1500
Mailing Address - Fax:502-589-1556
Practice Address - Street 1:1536 STORY AVE
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40206-1738
Practice Address - Country:US
Practice Address - Phone:502-589-1500
Practice Address - Fax:502-589-1556
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-17
Last Update Date:2010-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY41088207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY0842700001Medicare NSC
KY1340223Medicare PIN